J Head Trauma Rehabil

Vol. 28, No. 4, pp. 250–259

Copyright c 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Is Rest After Concussion “The Best

Medicine?”: Recommendations for
Activity Resumption Following
Concussion in Athletes, Civilians, and
Military Service Members
Noah D. Silverberg, PhD; Grant L. Iverson, PhD

Practice guidelines universally recommend an initial period of rest for people who sustain a sports-related concus-
sion or mild traumatic brain injury (MTBI) in daily life or military service. This practice is difficult to reconcile
with the compelling evidence that other health conditions can be worsened by inactivity and improved by early
mobilization and exercise. We review the scientific basis for the recommendation to rest after MTBI, the challenges
and potential unintended negative consequences of implementing it, and how patient management could be im-
proved by refining it. The best available evidence suggests that complete rest exceeding 3 days is probably not
helpful, gradual resumption of preinjury activities should begin as soon as tolerated (with the exception of activities
that have a high MTBI exposure risk), and supervised exercise may benefit patients with persistent symptoms.
Key words: brain injury, concussion, exercise, military, sports

Author Affiliations: GF Strong Rehab Centre & Department of

Medicine, Division of Physical Medicine & Rehabilitation (Dr Silverberg)
and Department of Psychiatry (Dr Iverson), University of British
Columbia, Vancouver, British Columbia, Canada; and Defense and
Veterans Brain Injury Center, Washington DC (Dr Iverson).
The views expressed in this article are those of the authors and do not reflect the
official policy of the US Department of Defense or US Government.
The Vancouver Coastal Health Research Institute provided salary support for
Dr Silverberg but was in no way involved in the in the writing of the manuscript
or the decision to submit it for publication.
Dr Silverberg receives funding from the Vancouver Coastal Health Research
Institute and the BC Rehab Foundation. Dr Iverson has been reimbursed by
the government, professional scientific bodies, and commercial organizations
for discussing or presenting research relating to MTBI and sports-related con-
cussion at meetings, scientific conferences, and symposiums. He has a clinical
practice in forensic neuropsychology involving individuals who have sustained
MTBIs. He has received honorariums for serving on research panels that pro-
vide scientific peer review of programs (eg, the Military Operational Medicine
Research Program). He is a coinvestigator, collaborator, or consultant on grants
funded by several organizations, including, but not limited to, the Canadian
Institute of Health Research, Alcohol Beverage Medical Research Council,
Rehabilitation Research and Development Service of the US Department of
Veterans Affairs, AstraZeneca Canada, and Lundbeck Canada.
The authors declare no conflicts of interest.
Corresponding Author: Noah Silverberg, PhD, GF Strong Re-
hab Centre, 4255 Laurel St, Vancouver, BC V5Z 2G9, Canada
(noah.silverberg@vch.ca).
DOI: 10.1097/HTR.0b013e31825ad658
250
R EST has long been considered “the best medicine”
for mild traumatic brain injury (MTBI). Prior to
the 1940s, it was standard practice to routinely impose
weeks of complete bed rest for patients with a loss of
consciousness of any duration.1 Contemporary practice
guidelines for MTBI still universally recommend an ini-
tial period of rest.2–5 The Zurich Consensus guidelines
for sports-related concussion, perhaps the most widely
used, highlight rest as the “cornerstone of concussion
management”.5(pi78) Accordingly, when patients present
for medical attention following an MTBI in sports, civil-
ian life, or military service, rest is one of the most com-
mon recommendations they will receive.6 Education
materials for patients who sustain an MTBI also unan-
imously encourage rest (for eg, reference 7–9). There is
less agreement, however, on the exact nature and du-
ration of the rest period. Healthcare professionals and
patients interpret advice to “rest” along a spectrum from
partial activity restriction to recumbence in bed. The
Veteran Administration/Department of Defense Prac-
tice Guidelines clarify that complete bed rest is not
recommended, but rather “a restful pattern of activity
throughout the day with minimal physical and men-
tal exertion.” 2(p35) Physical rest has been emphasized

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Is Rest After Concussion “The Best Medicine?”
in the past, although authors are increasingly stressing
the importance of cognitive rest, such as by reducing
work/school demands, computer and cell phone use,
and exposure to loud music.5,10 The recommended du-
ration of rest is also variable and often undefined. Some
advise fairly specific timelines (for eg, ref 3), but the
most widely adopted timeline is “until asymptomatic,”5
That is, patients who sustain an MTBI should rest until
they are no longer experiencing postconcussion symp-
toms. At that point, a graded resumption of activities
is considered best practice.5 Although this protocol was
developed for sport concussion, it has penetrated clini-
cal practice across other settings.2–4
There are several possible problems with this ap-
proach to MTBI management. First, the benefits of rest
are largely assumed rather than evidence based. In light
of the considerable evidence that other health condi-
tions can be worsened by inactivity and improved by
exercise, it may be imprudent to advise rest beyond the
acute stage. Second, defining asymptomatic status can
be very challenging, for reasons outlined later. Third,
a minority of patients who sustain this injury remain
symptomatic for months to years. Ongoing inactivity
is almost certainly more detrimental than therapeutic
in the chronic stage. This article will review the scien-
tific basis of the recommendation to rest after MTBI,
the challenges and potential unintended negative con-
sequences of implementing it, and how MTBI manage-
ment could be improved by refining it.
WHY QUESTION REST?
Rest to the affected organ is a cardinal principle in the treat-
ment of disease.11(p406)
Rest may be the most prescribed medical interven-
tion in history. Around the middle of the 20th century,
clinicians and researchers began to question the unqual-
ified adage that rest “is the best medicine.” In response
to emerging scientific evidence, the management of sev-
eral health conditions has changed dramatically toward
decreasing periods of rest and increasing early activation
and exercise. For example, a lengthy period of bed rest
was the treatment of choice for acute low back pain. A
seminal study by Deyo et al12 demonstrated that 2 days
of rest had better outcomes than 7 days. Since numer-
ous randomized controlled trials and systematic reviews
have supported the view that advice to stay active is more
effective than advice to rest after acute low back pain
with regard to both pain and functional outcome.13–15
Whiplash injury is another example. Whereas collar re-
straint and rest was the standard of care, there is now
substantial evidence that early mobilization and exer-
cise is not only safe but also achieves superior functional
outcomes.16–19 Psychiatry also has a history of impos-
ing rest as the primary treatment for mental disorders.20
Finally, consider the example of stroke. After a retro-
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
251
spective analysis revealed that earlier mobilization and
mental stimulation was most predictive of prompt dis-
charge home,21 researchers began to study it as an inter-
vention with randomized controlled trial methodology.
Mobilization within 24 hours has now been shown to
reduce the risk of certain complications,22 while maxi-
mizing independence at follow-up23 and decreasing rates
of depression.24 Summarizing much of this research, a
review of 39 clinical trials of bed rest following a med-
ical procedure and an additional 15 trials where bed
rest was examined as a primary intervention for a vari-
ety of health conditions concluded that bed rest has no
benefits and may cause harm.25 The authors cautioned
against assuming that rest is helpful and suggest that it
should be subject to the same methodologically rigorous
evaluation as any other intervention.
In parallel with this outcome research, observational
studies have documented the negative consequences of
protracted inactivity in patients with various health con-
ditions. Being sedentary after an injury or illness is one of
the most consistent risk factors for chronic disability.16
In chronic fatigue syndrome, rest does not alleviate
chronic fatigue, but rather, is thought to contribute to
its maintenance.26,27 Excessive activity restrictions may
also play a role in the maintenance of chronic pain.28,29
In vestibular disorders, motion induces dizziness and
imbalance, and as a result, distress. Many patients there-
fore avoid activities that require head movement, which
unfortunately limits central nervous system adaptation
and symptom resolution.30,31
Low levels of activity may also have serious men-
tal health consequences. An injury or illness appears
to raise susceptibility to depression to the extent that a
patient does not engage in his or her regular reinforc-
ing activities.32 Activity restrictions have been shown
to moderate the relationship between injury/illness
and mental health outcome in breast cancer,32 limb
amputation,33 and stroke.34 Limited opportunities for
positive reinforcement has long been considered a cen-
tral causal mechanism in depression,35 and increasing
positively reinforcing activities is the primary treatment
target of “behavioral activation,” one of the most ef-
fective treatments for depression.36 Low self-esteem and
self-efficacy after injury may contribute to avoidance
of activities perceived as challenging.37 Anxiety may
also be a cause and consequence of excessive activity
restriction. Fear about exacerbating symptoms and/or
reinjury often underlies inactivity in chronic fatigue
syndrome38 and chronic pain,39 and may as well in pa-
tients with persistent symptoms after MTBI—especially
those with vestibular problems. Avoidance of feared ac-
tivities, in turn, maintains or strengthens negative pre-
dictions and self-evaluations, creating a self-perpetuating
cycle. A heightened sense of vulnerability and avoidance
of threatening situations are core features of posttrau-
matic stress disorder.
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252 JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2013
To summarize, inactivity can precipitate, exacerbate,
and/or prolong recovery from many health conditions,
including those most often comorbid with MTBI—
vestibular disorders, depression, posttraumatic stress dis-
order, chronic fatigue, and pain disorders. Biopsychoso-
cial recovery from MTBI may be similarly affected by
excessive rest, but we must be cautious in extrapolating
evidence from other health conditions. At the very least
though, routine recommendations to rest after MTBI
warrant careful scrutiny. A finale rationale comes from
experimental studies of bed rest in healthy participants.
Prescribed rest begins to adversely affect the cardiopul-
monary and musculoskeletal systems in healthy peo-
ple within 3 days.40 Deconditioning over this period is
even more apparent in athletes.41 After 3 to 6 days of
bed rest, complaints of headache, restlessness, and dif-
ficulty sleeping, and after a week, mood changes, and
vestibular sensitivity are common.42 Thus, it appears
that complete bed rest beyond a few days is sufficient
to cause postconcussion-like symptoms and may exac-
erbate symptoms after MTBI.
THE BENEFITS OF EARLY REST AND RISKS
OF EXCESSIVE ACTIVITY AFTER MTBI
Recommendations for rest after an MTBI are derived
from expert consensus. One concern with prompt activ-
ity resumption after sports-related concussion seems to
be a heightened risk of reinjury. Repeat MTBI is most
likely to occur within days of the initial injury43,44 and
there is evidence from animal research that the brain
may be especially vulnerable to a second injury if it oc-
curs before recovery from the initial MTBI.45–47 This is
a reasonable rationale for withholding patients from ac-
tivities with heightened head trauma exposure risk (eg,
athletes returning to contact sport and military service
personnel returning to combat), but not physical activ-
ity, exercise, or cognitive exertion per se.
A prominent reason for cautioning athletes, civilians,
and service members against excessive activity in the
acute postinjury period is based on the theoretical
possibility that it might magnify the acute patho-
physiology of the injury. Animal models suggest that
MTBI results in a neurometabolic response involving
ionic fluxes, impaired neurotransmission, and increased
energy consumption devoted to neural repair and
return to homeostasis, in the context of decreased
energy availability.48,49 Therefore, placing high energy
demands on the system through physical and/or
mental exertion could compromise restorative events.
Functional neuroimaging studies have reported that
excessive (compensatory) brain activation is necessary
to maintain performance levels after MTBI,50 suggesting
that the threshold for exertion may also be lowered.
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The observation that exertion can even temporarily
provoke or worsen postconcussion symptoms in some
patients51–53 underscores this concern for many clin-
icians. However, such exacerbations may not be en-
tirely attributable to a mismatch between high energy
demands and limited energy availability (during acute
neurometabolic restoration) because exertion provokes
postconcussion-like symptoms in patients with very re-
mote MTBIs (in the Hanna-Pladdy et al51 sample, ∼80%
were more than 1 year postinjury and ∼50% were more
than 4 years). Moreover, exertion can provoke some
symptoms in healthy adults without a history of MTBI
(but typically requires greater exercise intensity, at least
in physically active young adults).54,55
Long-term adverse consequences of early activity suf-
ficient to provoke or exacerbate symptoms have been
hypothesized, but to date, only studied in animal mod-
els. Griesbach and colleagues56,57 found that molecu-
lar markers of plasticity (eg, brain-derived neurotrophic
factor and synapsin I) and behavioral (maze test) perfor-
mance in rats could be facilitated by voluntary exercise
1 to 2 weeks after experimentally induced MTBI. How-
ever, rats that were permitted use of a running wheel
during the initial 1 to 2 weeks had worse neuromolecu-
lar and behavioral outcome. They concluded that pre-
mature vigorous exercise can be detrimental to MTBI
recovery.
Given these concerns, experimental trials of vigorous
exercise cannot be ethically undertaken with human par-
ticipants in the initial days following MTBI while the
subject is highly symptomatic. A few studies have ex-
amined early interventions that involve graded activity
resumption,58,59 but it is not possible to isolate the effect
of this treatment component in their complex interven-
tions. Another randomized controlled trial directly ex-
amined the benefits of early versus later mobilization.60
The authors assigned all of their participants to a taper-
ing rest schedule of a maximum of 4 hours of bed rest
on the first day down to no bed rest (ie, full activity) on
the fifth day. Half of participants began this schedule
on the day after their MTBI and the other half started
it only after 6 days of complete bed rest. An initial pe-
riod of complete bed rest was associated with somewhat
lower visual analogue ratings for 14 of 16 postconcus-
sion symptoms at 2 weeks postinjury, but there were
statistically significant differences on only 1 of 16 symp-
toms. Six months later, this benefit “completely disap-
peared or was even reversed.”60(p172) Of note, cognitive
rest was not explicitly controlled. Participants may have
complied with the instructions to spend time in bed,
but could have been performing cognitively demanding
activities while in bed.
Observational studies of activity levels after MTBI
can also be informative. Majerske et al61 followed a co-
hort of student athletes (mean age ∼16 years) as they
 Is Rest After Concussion “The Best Medicine?”
recovered from concussion. The students were retro-
spectively assigned to groups based on their self-reported
activity level at the time of their follow-up visits to a con-
cussion clinic. Students who reported moderate levels of
cognitive and physical exertion (participation in school
and light jogging) over the first month after MTBI had
better neuropsychological outcomes than those with
minimal (no school or exercise activity) and high levels
of activity (school activity and participation in a sports
game). Although causal explanations cannot be drawn
from the Majerske et al study, their findings do suggest
that under- and overactivity may both be problematic.
Consistent with this notion, a recent prospective study
recruiting cases with MTBI from an emergency depart-
ment reported that the behavioral pattern of cycling be-
tween excessive activity (pushing through) and complete
rest (crashing) over the first 2 weeks following injury pre-
dicted postconcussion syndrome diagnosis at 3- and 6-
month follow-ups.62
EXERCISE AS A TREATMENT FOR MTBI
Recommending an extended period of rest after MTBI
is difficult to reconcile with the substantial literature
documenting the benefits of exercise. Graded aerobic ex-
ercise is now established as an effective intervention for
chronic fatigue,63,64 depression,65,66 and anxiety,67 and
it appears to improve cognition in people with neuro-
logical disorders68 and in older adults.69 The mechanism
underlying these gains is probably multifaceted (eg, car-
diopulmonary, neuroendocrine, neurometabolic, and
psychological). Exercise influences multiple neurotrans-
mitter systems and promotes neuroplasticity, neurogen-
esis, and angiogenesis.70,71 Exercise has been promoted
as an intervention for persistent symptoms after MTBI
for these reasons72,73 as well as in response to the practi-
cal challenge of some patients (particularly children and
adolescents) engaging in vigorous activity against med-
ical advice.74 Moreover, exercise may help normalize
cerebral autoregulation.75
To date, 3 uncontrolled studies have examined
exercise-based interventions for patients who do not re-
cover well from MTBI. Gagnon et al74 enrolled children
who sustained a sports-related concussion and were still
symptomatic at least 1 month following injury. After
participation in a program involving submaximal aer-
obic training and coordination exercises, all patients
had improved postconcussion symptoms and success-
fully returned to sports. Two significant limitations war-
rant mention. Because this was a multifaceted interven-
tion, the exercise component may not be responsible
for the treatment effect. Also, with no control group,
changes over the study period may be at least partially
attributable to spontaneous recovery. In a study with
adults, Leddy et al52 progressed patients through daily
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
253
treadmill exercise that was individualized to their thresh-
old for provoking symptoms, using a reliable assessment
protocol.76 After being symptomatic for 6 to 52 weeks
at the time of enrolment, this group achieved large im-
provements in postconcussion symptoms and had no
adverse events over a 5-week (average) intervention pe-
riod. A follow-up study reported outcome data from
a cohort of 63 patients who received the same graded
exercise intervention at the same clinic 8 months post-
MTBI, on average.77 The study’s methodology severely
limits conclusions about efficacy, but of note, most pa-
tients found the treatment acceptable (only 10% de-
clined) and treatment outcomes were similar whether
or not the initial exercise test provoked symptoms. Al-
though randomized controlled trials are needed to better
understand the safety and efficacy of exercise for chronic
postconcussion symptoms, this type of intervention has
clear promise.
Cognitive rehabilitation (of which “cognitive exer-
cise” is usually a central component) is not well-
supported as a treatment for the chronic postconcus-
sion syndrome.78,79 It may be more effective if delivered
earlier after MTBI, but this remains to be established
empirically. Because neuroplasticity is experience de-
pendent, cognitive exercise may be especially useful for
patients with structural brain lesions from an MTBI.
There is evidence that “enriched environments” and
practice with specific tasks that activate the affected neu-
ral circuitry can facilitate reorganization and functional
recovery from focal brain damage.80,81
DETERMINING ASYMPTOMATIC STATUS
IS CHALLENGING
In deciding when to shift from recommending rest
to graded activity resumption and exercise, concussed
athletes are encouraged to wait until they are “asymp-
tomatic.” In clinical practice, this recommendation
might be extrapolated to patients with other injury
mechanisms (eg, motor vehicle accident). The “un-
til asymptomatic” criterion makes intuitive sense but
is very difficult to implement. Alla and colleagues55
recently reviewed several of these reasons. In short,
postconcussion symptom reporting is influenced by a
wide range of pre-, peri-, and postinjury biopsychosocial
factors,82,83 including assessment method,84 social psy-
chological factors,85,86 psychiatric comorbidity,87,88 per-
sonality characteristics,89 and motivation.90,91 Healthy
respondents without any head trauma history report
postconcussion-like symptoms.92 Failure to achieve
asymptomatic status, then, does not necessarily mean
incomplete neurobiological recovery from MTBI. Fur-
ther to Alla et al,50 the converse also appears true. Be-
cause subjective symptoms resolve before normalization
of objective markers of brain function (eg, functional
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254 JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2013
magnetic resonance imaging) in some patients,93–95
asymptomatic status does not rule out brain vulner-
ability. It may therefore not be the most appropriate
criterion for readiness to resume activity.
There is also no evidence that using asymptomatic sta-
tus to guide activity resumption improves outcomes. On
the contrary, at least with respect to preventing repeat
MTBI, a universal timeline might work better. McCrea
and colleagues43 found that the risk of repeat concus-
sion was highest in athletes who returned to competition
within the first week following injury, regardless of their
symptomatic status. Requiring a symptom-free waiting
period before return to sports did not confer protection
against repeat concussion. Their data suggest that “rest”
in the form of delaying return to competitive sports may
be better informed by a universal period of 7 to 10 days
than by symptom monitoring.43
Others have proposed that the timing of activity
resumption should still be informed by an individual’s
recovery status, but recovery should be tracked by
methods other than symptom reporting. Neuropsy-
chological testing has been widely recommended for
tracking recovery.96–98 Vagnozzi et al95 suggested that
activity resumption could be guided by neurometabolic
recovery status, as measured by proton magnetic
resonance spectroscopy. However, the most sensitive
and reliable clinical biomarkers of neurometabolic
recovery are still under investigation95,99 and these
experimental neuroimaging approaches are not feasible
in day-to-day clinical practice.
WHAT ABOUT PATIENTS WHO REMAIN
SYMPTOMATIC AT REST?
Most patients who incur an MTBI experience symp-
tom resolution within days to weeks. However, some
report persistent symptoms beyond 3 months postin-
jury, in what is referred to as postconcussional syndrome
or postconcussive disorder.100,101 Although this is an
atypical outcome from MTBI, given the very high inci-
dence of MTBIs in sports, military, and civilian trauma
settings,102 the absolute number of cases is large. For
those patients with chronic symptoms and low activity
levels, more rest is surely not the solution to improve
their condition. Rather, physical deconditioning, avoid-
ance behavior, and a lack of mastery experiences likely
contribute to disability, and graded activity resumption
is considered an important component in clinical man-
agement of these patients.2,75,79,103
EVIDENCE-BASED RECOMMENDATIONS
FOR REST AFTER MTBI
In medicine, rest is often prescribed by default when
the presenting condition is poorly understood.14,20 As
research has better characterized acute low back pain,
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
whiplash injury, stroke, myocardial infarction, preg-
nancy miscarriage, infectious mononucleosis, arthritis,
and other health conditions over the past 50 to 60
years, there has been a distinct trend toward recom-
mending less rest and more activity in their clinical
management.
There may be a lesson here for the MTBI field. The
conceptualization of MTBI has evolved considerably,
but clinical strategies to facilitate recovery lag behind.
At present, rest and “watchful waiting” for symptom res-
olution is usual care following athletic injury5 as well as
MTBI incurred in other settings. However, a patient’s
postinjury activity level may be one of the biopsychoso-
cial factors that modifies the trajectory of recovery from
MTBI and therefore may represent a viable treatment
target. This review of the research evidence in animals
and humans converges on the basic message that after
an MTBI, although some rest may be good, too much
is bad. Our conclusions from this literature are summa-
rized below.
1. There is no evidence that complete rest (recum-
bence in bed and avoidance of cognitive stimula-
tion) for any duration improves or adversely im-
pacts outcome after MTBI. The only randomized
controlled trial had null results. Multiple system-
atic reviews for many health conditions other than
MTBI have concluded that full bed rest beyond
1 to 2 days is unhelpful and potentially harmful.
Negative physiological consequences of prescribed
rest are evident after as little as 3 days.
2. Returning to competitive sports within the first
week following injury is associated with an elevated
risk of repeat concussion, regardless of whether the
athlete is symptomatic or asymptomatic.
3. Vigorous exercise within the first 2 weeks following
injury might delay recovery in some people, partic-
ularly those who are more seriously injured. This is
based on experimental research with rats56,57 and
one observational study with student athletes.61
4. Graded resumption of regular preinjury activities
(with the exception of competitive sports) as tol-
erated within the first few days to weeks postin-
jury, regardless of symptomatic status, is more
likely to speed up than delay recovery. Multiple
randomized clinical trials of early intervention in-
cluded a guided activation component and found
benefit for the full (multicomponent) intervention
package.58,59 In one study, starting this process on
the day after injury temporarily exacerbated symp-
toms but achieved the same long-term outcome
as delaying it by a few days.60 Delaying graded re-
sumption of regular preinjury activities beyond a
month may worsen outcome.61
5. Physical mobilization can facilitate recovery from
cervical soft tissue injury17–19 and vestibular
 Is Rest After Concussion “The Best Medicine?”
disorders,104,105 which often co-occur with MTBI
and contribute to persistent symptoms.101
6. Regular engagement in valued activities may guard
against the development of depression and anxiety
after MTBI.
7. Exercise that is below the threshold to exacerbate
symptoms is probably safe and potentially bene-
ficial after 1-month postinjury. This is based on
experimental research with rats56,57 and 2 human
case series.52,106
8. Physical and/or mental exertion can temporar-
ily exacerbate postconcussion symptoms at any
stage of recovery (as well as elicit postconcussion-
like symptoms in uninjured adults). It is unclear
whether this has any long-term neuropathological
or functional consequences.
TABLE 1 Evidence ratings for practice
recommendations
Evidence
Rating Description
A A strong recommendation that the
clinicians provide the intervention to
eligible patients.
Good evidence was found that the
intervention improves important health
outcomes and concludes that benefits
substantially outweigh harm.
B A recommendation that clinicians provide
(the service) to eligible patients.
At least fair evidence was found that the
intervention improves health
outcomes and concludes that benefits
outweigh harm.
C No recommendation for or against the
routine provision of the intervention is
made.
At least fair evidence was found that the
intervention can improve health
outcomes, but concludes that the
balance of benefits and harms is too
close to justify a general
recommendation.
D Recommendation is made against
routinely providing the intervention to
patients.
At least fair evidence was found that the
intervention is ineffective or that
harms outweigh benefits.
I The conclusion is that the evidence is
insufficient to recommend for or
against routinely providing the
intervention.
Evidence that the intervention is
effective is lacking, or poor quality, or
conflicting, and the balance of benefits
and harms cannot be determined.
From The Management of Concussion/mTBI Working Group2
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
255
We now arrive at an important clinical question:
When should we encourage patients to make the transi-
tion from rest to activity resumption after MTBI? In
current practice, determining readiness for this tran-
sition is done on an individualized basis by moni-
toring symptom resolution. On the basis of our syn-
thesis of the best available evidence (see Table 1 for
Strength of recommendation grades), we provide the 5
recommendations listed in Table 2. We believe these
recommendations are appropriate for athletes, civil-
ian trauma patients, military service members, and
veterans.
We caution against rigid implementation of these rec-
ommendations. The management of MTBI in sports,
civilian life, and military service should be guided by
individual patient circumstances and characteristics, in-
cluding, but not limited to, preinjury health status, in-
jury severity, co-occurring injuries, and the postinjury
evolution of comorbidities. Children may also require
more conservative management.5
Our recommendations depart from the “rest until
asymptomatic” guideline,5 especially as they are applied
to nonathletes, where symptom resolution takes on
average weeks rather than days.107–109 The suggestion
of physical and cognitive rest for a “few days” by
McCrea et al108 comes closer to our recommenda-
tions, but they recommend “vigorous exercise” only
once asymptomatic. On the basis of a model of
neurometabolic recovery, Vagnozzi et al95 suggest
TABLE 2 Recommendations for activity
resumption following MTBI
1. Bed rest exceeding 3 days is not recommended.
(Strength of recommendation = D)
2. Gradual resumption of preinjury activities should
begin as soon as tolerated. (Strength of
recommendation = B)
3. For contact sports and other activities with a high
MTBI exposure risk, a delay of at least 1 week will
help reduce the risk of overlapping injuries.
(Strength of recommendation = B)
4. The medium- and long-term risks of exertion
sufficient to exacerbate symptoms are unknown.
In theory, during the acute recovery period (eg,
first 2 weeks postinjury), heavy exertion that
elicits significant symptoms could be harmful. We
simply do not know. In response to symptom
exacerbations, patients should therefore be
advised to temporarily reduce their physical and
cognitive demands and resume their graduated
return to activity at a slower pace. (Strength of
recommendation = I)
5. After 1 month, supervised exercise should be
considered as part of the treatment plan for
individuals who remain symptomatic. (Strength of
recommendation = C)
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256 JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2013
complete rest for the first 2 weeks. Although biomarkers
of neurometabolism may begin to normalize only after
2 weeks,95 our review suggests that modest activity
levels (not vigorous) are more likely to help than harm
early MTBI recovery.
Compliance with prescribed activity restrictions and
activity resumption could probably be improved with
detailed concrete instructions and active monitoring.
Vague instructions such as to start with “a little
bit” of exercise are vulnerable to misinterpretation.110
Rather than merely discharging patients from the emer-
gency department with advise to rest, scheduled tele-
phone calls to monitor adherence to a graduated ac-
tivity resumption plan and to engage in collaborative
problem solving around obstacles might improve MTBI
outcomes.59
Patients making little progress toward activity resump-
tion should be carefully evaluated. If querying reveals
that they are excessively limiting their activity to pre-
vent provocation of dizziness and imbalance, a diag-
nostic work-up for vestibular disorder should be consid-
REFERENCES
1. Symonds CP. Discussion on differential diagnosis and treatment
of post-contusional states. Proc R Soc Med. 1942;35:601–614.
2. The Management of Concussion/mTBI Working Group.
VA/DoD clinical practice guideline for management of concus-
sion/mild traumatic brain injury (mTBI). Vol 2010. Washington,
DC: Department of Veterans Affairs and Department of Defense;
2009.
3. Ingebrigtsen T, Romner B, Kock-Jensen C. Scandinavian guide-
lines for initial management of minimal, mild, and moderate
head injuries. The Scandinavian Neurotrauma Committee. J
Trauma. 2000;48:760–766.
4. Motor Accidents Authority New South Wales. Guidelines for mild
traumatic brain injury following closed head injury. Sydney, Australia:
Motor Accidents Authority; 2008.
5. McCrory P, Meeuwisse W, Johnston K, et al. Consensus state-
ment on concussion in sport: the 3rd International Conference
on Concussion in Sport held in Zurich, November 2008. Br J
Sports Med. 2009;(43)(suppl 1):i76–i90.
6. De Kruijk JR, Twijnstra A, Meerhoff S, Leffers P. Management of
mild traumatic brain injury: lack of consensus in Europe. Brain
Inj. 2001;15:117–123.
7. US Department of Health and Human Services, Cen-
ters for Disease Control and Prevention. Facts about
concussion and brain injury. Vol. 2011, http://www.cdc.
gov/concussion/pdf/Facts_about_Concussion_TBI-a.pdf. Pub-
lished 2010. Accessed May 22, 2012.
8. Battlemind Transition Office, Proponency Office for Rehabilita-
tion & Reintegration. Concussion/MTBI Information at the Time of
Injury (acute). 4.0 ed. Vol. 2011, http://www.dvbic.org/pdf/Acute-
Trifold.pdf. Published 2010. Accessed May 22, 2012.
9. ThinkFirst Canada. Return to play guidelines. Vol. 2011.
http://www.thinkfirst.ca/programs/documents/TF_Concussion_
RTP_E_2012.pdf. Accessed May 22, 2012.
10. Valovich McLeod TC, Gioia GA. Cognitive rest: the often ne-
glected aspect of concussion management. Athletic Therapy Today.
2010;15:1–3.
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ered. If they are avoiding activities because of unrealistic
feared consequences or in the context of low mood and
anhedonia, a mental health specialist should be involved
in their care. Moreover, clinicians should be alert to per-
sonality characteristics that may predispose patients to
rapidly and fully resume activities without graded pro-
gression and “push through” symptoms until they en-
counter catastrophic role failure.111
Early intervention providing education and reassur-
ance may be insufficient for patients who are ini-
tially highly symptomatic and on a trajectory of poor
outcome.112 Interventions that target the rest-activity
balance may improve MTBI care. Prescribing detailed
individualized hierarchical activity resumption plans,
monitoring adherence to them with scheduled tele-
phone calls, screening for obstacles to activity resump-
tion, and providing structured exercise programs are all
potentially effective treatment components. These po-
tential interventions should be subjected to clinical tri-
als. The optimal timing of these interventions must also
be empirically determined.
11. Levine SA. The myth of strict bed rest in the treatment of heart
disease. Am Heart J. 1951;42:406–413.
12. Deyo RA, Diehl AK, Rosenthal M. How many days of bed rest
for acute low back pain? A randomized clinical trial. N Engl J
Med. 1986;315:1064–1070.
13. Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The updated
Cochrane review of bed rest for low back pain and sciatica. Spine.
2005;30:542–546.
14. Waddell G, Feder G, Lewis M. Systematic reviews of bed rest
and advice to stay active for acute low back pain. Br J Gen Pract.
1997;47:647–652.
15. Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest
in bed versus advice to stay active for acute low-back pain and
sciatica. Cochrane Database Syst Rev. 2010:CD007612.
16. McLean SA, Clauw DJ. Predicting chronic symptoms after an
acute “stressor”—lessons learned from 3 medical conditions. Med
Hypotheses. 2004;63:653–658.
17. Schnabel M, Ferrari R, Vassiliou T, Kaluza G. Randomised, con-
trolled outcome study of active mobilisation compared with col-
lar therapy for whiplash injury. Emerg Med J. 2004;21:306–310.
18. Soderlund A, Olerud C, Lindberg P. Acute whiplash-associated
disorders (WAD): the effects of early mobilization and prognostic
factors in long-term symptomatology. Clin Rehabil. 2000;14:457–
467.
19. Teasell RW, McClure JA, Walton D, et al. A research synthe-
sis of therapeutic interventions for whiplash-associated disorder
(WAD): part 2—interventions for acute WAD. Pain Res Manag.
2010;15:295–304.
20. Menninger K. The abuse of rest in psychiatry. J Am Med Assoc.
1944;125:1087–1092.
21. Indredavik B, Bakke F, Slordahl SA, Rokseth R, Haheim LL.
Treatment in a combined acute and rehabilitation stroke unit:
which aspects are most important? Stroke. 1999;30:917–923.
22. Bernhardt J, Dewey H, Thrift A, Collier J, Donnan G. A very
early rehabilitation trial for stroke (AVERT): phase II safety and
feasibility. Stroke. 2008;39:390–396.
 Is Rest After Concussion “The Best Medicine?”
23. Craig LE, Bernhardt J, Langhorne P, Wu O. Early mobiliza-
tion after stroke: an example of an individual patient data
meta-analysis of a complex intervention. Stroke. 2010;41:2632–
2636.
24. Cumming TB, Collier J, Thrift AG, Bernhardt J. The effect of
very early mobilisation after stroke on psychological well-being.
J Rehabil Med. 2008;40:609–614.
25. Allen C, Glasziou P, Del Mar C. Bed rest: a potentially
harmful treatment needing more careful evaluation. Lancet.
1999;354:1229–1233.
26. Clark LV, White PD. The role of deconditioning and therapeu-
tic exercise in chronic fatigue syndrome (CFS). Journal of mental
Health. 2005;14:237–252.
27. Vercoulen JH, Swanink CM, Galama JM, et al. The persistence
of fatigue in chronic fatigue syndrome and multiple sclerosis:
development of a model. J Psychosom Res. 1998;45:507–517.
28. Philips HC. Avoidance behaviour and its role in sustaining
chronic pain. Behav Res Ther. 1987;25:273–279.
29. Verbunt JA, Seelen HA, Vlaeyen JW, et al. Disuse and decondi-
tioning in chronic low back pain: concepts and hypotheses on
contributing mechanisms. Eur J Pain. 2003;7:9–21.
30. Gurr B, Moffat N. Psychological consequences of vertigo and the
effectiveness of vestibular rehabilitation for brain injury patients.
Brain Inj. 2001;15:387–400.
31. Yardley L, Redfern MS. Psychological factors influencing recov-
ery from balance disorders. J Anxiety Disord. 2001;15:107–119.
32. Williamson GM, Shaffer DR. The activity restriction model of
depressed affect: Antecedents and consequences of restricted nor-
mal activities. In: Williamson GM, Shaffer DR, Parmelee PA, eds.
Physical illness and depression in older adults: A handbook of theory,
research, and practice. New York: Kluwer Academics/Plenum Pub-
lishers; 2000:173–200.
33. Williamson GM, Schulz R, Bridges M, Behan A. Social and
psychological factors in adjustment to limb amputation. Journal
of Social and Behavior and Personality. 1994;9:249–268.
34. Landreville P, Desrosiers J, Vincent C, Verreault R, Boudreault V.
The role of activity restriction in poststroke depressive symptoms.
Rehabil Psychol. 2009;54:315–322.
35. Lewinsohn PM, Biglan A, Zeiss AS. Behavioral treatment of
depression. In: Davidson PO, ed. The behavioral Management of
Anxiety, Depression and Pain. Oxford, England: Brunner/Mazel;
1976:91–146.
36. Veale D. Behavioural activation for depression. Adv Psychiatr
Treatment. 2008;14:29–36.
37. Riley GA, Dennis RK, Powell T. Evaluation of coping resources
and self-esteem as moderators of the relationship between threat
appraisals and avoidance of activities after traumatic brain injury.
Neuropsychol Rehabil. 2010;20:869–882.
38. Deale A, Chalder T, Wessely S. Illness beliefs and treatment
outcome in chronic fatigue syndrome. J Psychosom Res. 1998;45:
77–83.
39. Lohnberg JA. A review of outcome studies on cognitive-
behavioral therapy for fearing fear-avoidance belief among
individuals with chronic pain. J Clin Psychol Med Settings.
2007;14:113–122.
40. Winkelman C. Bed rest in health and critical illness: a body
systems approach. AACN Adv Crit Care. 2009;20:254–266.
41. Smorawinski J, Nazar K, Kaciuba-Uscilko H, et al. Effects of 3-day
bed rest on physiological responses to graded exercise in athletes
and sedentary men. J Appl Physiol. 2001;91:249–257.
42. Fortney SM, Schneider VS, Greenleaf JE. The physiology of
bed rest. Compr Physiol. 2011:889–939. http://onlinelibrary.wiley.
com/doi/10.1002/cphy.cp040239/full.
43. McCrea M, Guskiewicz K, Randolph C, et al. Effects of a
symptom-free waiting period on clinical outcome and risk of rein-
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
257
jury after sport-related concussion. Neurosurgery. 2009;65:876–
882; Discussion 882–873.
44. Guskiewicz KM, McCrea M, Marshall SW, et al. Cumulative
effects associated with recurrent concussion in collegiate football
players: the NCAA Concussion Study. JAMA. 2003;290:2549–
2555.
45. Laurer HL, Bareyre FM, Lee VM, et al. Mild head injury increas-
ing the brain’s vulnerability to a second concussive impact. J
Neurosurg. 2001;95:859–870.
46. Longhi L, Saatman KE, Fujimoto S, et al. Temporal window of
vulnerability to repetitive experimental concussive brain injury.
Neurosurgery. 2005;56:364–374; Discussion 364–374.
47. Signoretti S, Vagnozzi R, Tavazzi B, Lazzarino G. Biochemical
and neurochemical sequelae following mild traumatic brain in-
jury: summary of experimental data and clinical implications.
Neurosurg Focus. 2010;29:E1.
48. Barkhoudarian G, Hovda DA, Giza CC. The molecular
pathophysiology of concussive brain injury. Clin Sports Med.
2011;30:33–48, vii-iii.
49. Giza CC, Hovda DA. The neurometabolic cascade of concus-
sion. J Athl Train. 2001;36:228–235.
50. Jantzen KJ. Functional magnetic resonance imaging of mild trau-
matic brain injury. J Head Trauma Rehabil. 2010;25:256–266.
51. Hanna-Pladdy B, Berry ZM, Bennett T, Phillips HL, Gouvier
WD. Stress as a diagnostic challenge for postconcussive symp-
toms: sequelae of mild traumatic brain injury or physiological
stress response. Clin Neuropsychol. 2001;15:289–304.
52. Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH,
Willer B. A preliminary study of subsymptom threshold exercise
training for refractory post-concussion syndrome. Clin J Sport
Med. 2010;20:21–27.
53. Solomon GS. Letter: A comment on “exertion” after sports-
related concussion. J Neuropsychiatry Clin Neurosci. 2007;19:195–
196.
54. Alla S, Sullivan SJ, McCrory P, Schneiders AG, Handcock P.
Does exercise evoke neurological symptoms in healthy subjects?
J Sci Med Sport. 2010;13:24–26.
55. Alla S, Sullivan SJ, McCrory P. Defining asymptomatic status
following sports concussion: fact or fallacy? Br J Sports Med. 2012;
46(8):562–569.
56. Griesbach GS, Hovda DA, Molteni R, Wu A, Gomez-Pinilla
F. Voluntary exercise following traumatic brain injury: brain-
derived neurotrophic factor upregulation and recovery of func-
tion. Neuroscience. 2004;125:129–139.
57. Griesbach GS, Hovda DA, Gomez-Pinilla F. Exercise-induced
improvement in cognitive performance after traumatic brain
injury in rats is dependent on BDNF activation. Brain Res.
2009;1288:105–115.
58. Mittenberg W, Tremont G, Zielinski RE, Fichera S, Rayls KR.
Cognitive-behavioral prevention of postconcussion syndrome.
Arch Clin Neuropsychol. 1996;11:139–145.
59. Bell KR, Hoffman JM, Temkin NR, et al. The effect of tele-
phone counselling on reducing post-traumatic symptoms after
mild traumatic brain injury: a randomised trial. J Neurol Neuro-
surg Psychiatry. 2008;79:1275–1281.
60. de Kruijk JR, Leffers P, Meerhoff S, Rutten J, Twijnstra A. Ef-
fectiveness of bed rest after mild traumatic brain injury: a ran-
domised trial of no versus six days of bed rest. J Neurol Neurosurg
Psychiatry. 2002;73:167–172.
61. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports:
postconcussive activity levels, symptoms, and neurocognitive
performance. J Athl Train. 2008;43:265–274.
62. Hou R, Moss-Morris R, Peveler R, Mogg K, Bradley BP, Belli
A. When a minor head injury results in enduring symptoms:
a prospective investigation of risk factors for postconcussional
www.headtraumarehab.com
258 JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2013
syndrome after mild traumatic brain injury. J Neurol Neurosurg
Psychiatry. 2012;83:217–223.
63. Edmonds M, McGuire H, Price J. Exercise therapy for chronic
fatigue syndrome. Cochrane Database Syst Rev. 2004:CD003200.
64. White PD, Goldsmith KA, Johnson AL, et al. Comparison of
adaptive pacing therapy, cognitive behaviour therapy, graded ex-
ercise therapy, and specialist medical care for chronic fatigue syn-
drome (PACE): a randomised trial. Lancet. 2011;377:823–836.
65. Krogh J, Nordentoft M, Sterne JA, Lawlor DA. The effect of
exercise in clinically depressed adults: systematic review and
meta-analysis of randomized controlled trials. J Clin Psychiatry.
2011;72:529–538.
66. Mead GE, Morley W, Campbell P, Greig CA, McMurdo M,
Lawlor DA. Exercise for depression. Cochrane Database Syst Rev.
2009:CD004366.
67. Wipfli BM, Rethorst CD, Landers DM. The anxiolytic effects of
exercise: a meta-analysis of randomized trials and dose-response
analysis. J Sport Exerc Psychol. 2008;30:392–410.
68. McDonnell MN, Smith AE, Mackintosh SF. Aerobic exercise to
improve cognitive function in adults with neurological disorders:
a systematic review. Arch Phys Med Rehabil. 2011;92:1044–1052.
69. Smith PJ, Blumenthal JA, Hoffman BM, et al. Aerobic exercise
and neurocognitive performance: a meta-analytic review of ran-
domized controlled trials. Psychosom Med. 2010;72:239–252.
70. Neeper SA, Gomez-Pinilla F, Choi J, Cotman C. Exercise and
brain neurotrophins. Nature. 1995;373:109.
71. Cotman CW, Berchtold NC. Exercise: a behavioral interven-
tion to enhance brain health and plasticity. Trends Neurosci.
2002;25:295–301.
72. Iverson GL, Brooks BL, Azevedo A, Gaetz M. Modifying the
British Columbia Concussion Recovery Program for use with
injured adults with postconcussion syndrome; September 14–16,
2006; Miami, FL.
73. Iverson GL, Gagnon I, Griesbach GS. Active rehabilitation for
slow-to-recover children following mild traumatic brain injury.
In: Yeates KO, Kirkwood MW, eds. Pediatric Mild Traumatic Brain
Injury: From Basic Science to Clinical Management: Guilford Press.
In press.
74. Gagnon I, Galli C, Friedman D, Grilli L, Iverson GL. Active
rehabilitation for children who are slow to recover following
sport-related concussion. Brain Inj. 2009;23:956–964.
75. Willer B, Leddy JJ. Management of concussion and post-
concussion syndrome. Curr Treat Options Neurol. 2006;8:415–426.
76. Leddy JJ, Baker JG, Kozlowski K, Bisson L, Willer B. Reliability
of a graded exercise test for assessing recovery from concussion.
Clin J Sport Med. 2011;21:89–94.
77. Baker JG, Freitas MS, Leddy JJ, Kozlowski KF, Willer BS. Return
to full functioning after graded exercise assessment and progres-
sive exercise treatment of postconcussion syndrome. Rehabil Res
Pract. 2012;2012:705309.
78. Comper P, Bisschop SM, Carnide N, Tricco A. A systematic
review of treatments for mild traumatic brain injury. Brain Inj.
2005;19:863–880.
79. Snell DL, Surgenor LJ, Hay-Smith EJ, Siegert RJ. A systematic re-
view of psychological treatments for mild traumatic brain injury:
an update on the evidence. J Clin Exp Neuropsychol. 2009;31:20–
38.
80. Kleim JA, Jones TA. Principles of experience-dependent neural
plasticity: implications for rehabilitation after brain damage. J
Speech Lang Hear Res. 2008;51:S225–239.
81. Nithianantharajah J, Hannan AJ. Enriched environments,
experience-dependent plasticity and disorders of the nervous sys-
tem. Nat Rev Neurosci. 2006;7:697–709.
82. Iverson GL. Outcome from mild traumatic brain injury. Curr
Opin Psychiat. 2005;18:301–317.
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
83. Iverson GL. Biopsychosocial outcome from mild traumatic brain
injury. In: Vasterling J, Bryant R, Keane T, ed. PTSD and Mild
Traumatic Brain Injury. New York, NY: Guilford Press. In press.
84. Iverson GL, Brooks BL, Ashton VL, Lange RT. Interview vs.
questionnaire symptom reporting in people with post-concussion
syndrome. J Head Trauma Rehabil. 2010;25:25–30.
85. Suhr JA, Gunstad J. “Diagnosis Threat”: the effect of negative
expectations on cognitive performance in head injury. J Clin Exp
Neuropsychol. 2002;24:448–457.
86. Gunstad J, Suhr JA. “Expectation as etiology” versus “the good
old days”: postconcussion syndrome symptom reporting in ath-
letes, headache sufferers, and depressed individuals. J Int Neu-
ropsychol Soc. 2001;7:323–333.
87. Lange RT, Iverson GL, Rose A. Depression strongly in-
fluences postconcussion symptom reporting following mild
traumatic brain injury. J Head Trauma Rehabil. 2011;26:
127–137.
88. Suhr JA, Gunstad J. Postconcussive symptom report: the relative
influence of head injury and depression. J Clin Exp Neuropsychol.
2002;24:981–993.
89. Stulemeijer M, van der Werf SP, Jacobs B, et al. Impact of addi-
tional extracranial injuries on outcome after mild traumatic brain
injury. J Neurotrauma. 2006;23:1561–1569.
90. Lange RT, Iverson GL, Brooks BL, Ashton Rennison VL. Influ-
ence of poor effort on self-reported symptoms and neurocogni-
tive test performance following mild traumatic brain injury. J Clin
Exp Neuropsychol. 2010;32:961–972.
91. Mooney G, Speed J, Sheppard S. Factors related to recovery after
mild traumatic brain injury. Brain Inj. 2005;19:975–987.
92. Iverson GL, Lange RT. Examination of “postconcussion-like”
symptoms in a healthy sample. Appl Neuropsychol. 2003;10:137–
144.
93. Fazio VC, Lovell MR, Pardini JE, Collins MW. The relation
between post concussion symptoms and neurocognitive perfor-
mance in concussed athletes. NeuroRehabilitation. 2007;22:207–
216.
94. Slobounov SM, Zhang K, Pennell D, Ray W, Johnson B,
Sebastianelli W. Functional abnormalities in normally ap-
pearing athletes following mild traumatic brain injury:
a functional MRI study. Exp Brain Res. 2010;202:341–
354.
95. Vagnozzi R, Signoretti S, Cristofori L, et al. Assessment of
metabolic brain damage and recovery following mild traumatic
brain injury: a multicentre, proton magnetic resonance spec-
troscopic study in concussed patients. Brain. 2010;133:3232–
3242.
96. Echemendia RJ, Iverson GL, McCrea M, et al. Role of neuropsy-
chologists in the evaluation and management of sport-related
concussion: an inter-organization position statement. Arch Clin
Neuropsychol. 2011.
97. Moser RS, Iverson GL, Echemendia RJ, et al. Neuropsy-
chological evaluation in the diagnosis and management of
sports-related concussion. Arch Clin Neuropsychol. 2007;22:909–
916.
98. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement
statement of the First International Conference on Concussion in
Sport, Vienna 2001. Recommendations for the improvement of
safety and health of athletes who may suffer concussive injuries.
Br J Sports Med. 2002;36:6–10.
99. Yeo RA, Gasparovic C, Merideth F, Ruhl D, Doezema D, Mayer
AR. A longitudinal proton magnetic resonance spectroscopy
study of mild traumatic brain injury. J Neurotrauma. 2011;28:1–
11.
100. King NS, Kirwilliam S. Permanent post-concussion symptoms
after mild head injury. Brain Inj. 2011;25:462–470.
 Is Rest After Concussion “The Best Medicine?”
101. Iverson GL, Zasler ND, Lange RT. Post-concussive disorder. In:
Zasler ND, Katz HT, Zafonte RD, eds. Brain Injury Medicine:
Principles and Practice. New York, NY: Demos Medical Publishing;
2007:373–405.
102. Cassidy JD, Carroll LJ, Peloso PM, et al. Incidence, risk factors
and prevention of mild traumatic brain injury: results of the
WHO Collaborating Centre Task Force on mild traumatic brain
injury. J Rehabil Med. 2004;(43)(suppl):28–60.
103. Mittenberg W, Burton DB. A survey of treatments for post-
concussion syndrome. Brain Inj. 1994;8:429–437.
104. Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilita-
tion for dizziness and balance disorders after concussion. J Neurol
Phys Ther. 2010;34:87–93.
105. Gottshall K. Vestibular rehabilitation after mild traumatic
brain injury with vestibular pathology. NeuroRehabilitation.
2011;29:167–171.
106. Gagnon I, Swaine B, Forget R. Using activity diaries to mea-
sure children’s and adolescents’ compliance with activity restric-
tions after mild traumatic brain injury. J Head Trauma Rehabil.
2009;24:355–362.
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
259
107. Carroll LJ, Cassidy JD, Peloso PM, et al. Prognosis for mild
traumatic brain injury: results of the WHO Collaborating Cen-
tre Task Force on mild traumatic brain injury. J Rehabil Med.
2004;(43)(suppl):84–105.
108. McCrea M, Iverson GL, McAllister TW, et al. An inte-
grated review of recovery after mild traumatic brain injury
(MTBI): implications for clinical management. Clin Neuropsychol.
2009;23:1368–1390.
109. Ponsford J, Willmott C, Rothwell A, et al. Factors influencing
outcome following mild traumatic brain injury in adults. J Int
Neuropsychol Soc. 2000;6:568–579.
110. Swaine BR, Friedman DS. Activity restrictions as part of the
discharge management for children with a traumatic head injury.
J Head Trauma Rehabil. 2001;16:292–301.
111. Kay T, Newman B, Cavallo M, Ezrachi O, Resnick M. Toward
a neuropsychological model of functional disability after mild
traumatic brain injury. Neuropsychology. 1992;6:371–384.
112. Al Sayegh A, Sandford D, Carson AJ. Psychological approaches
to treatment of postconcussion syndrome: a systematic review. J
Neurol Neurosurg Psychiatry. 2010;81:1128–1134.
www.headtraumarehab.com