The ongoing campaign for later school-start times has shaped a narrative around kids and sleep, namely that they need a lot (and probably more) of it. In most cases, this is true. For the sake of healthy development, growing brains and bodies need to get their eight-to-nine hours. But sufficient, healthy sleep doesn’t translate to unlimited rest and relaxation. In fact, too much rest may be more ruinous than restorative for kids and teens.
A new neurology study highlights one scenario in which, contrary to medical industry standards, telling kids to “take it easy” may hurt more than help: concussion recovery. The research, published in the journal Clinical Pediatrics, says kids who incur concussions, also called mild traumatic brain injury (TBI), should resume their normal lives as soon as possible.
Until the early 1990s, concussions were, technically speaking, no big deal. Once kids stopped throwing up and seeing stars, they were free to go back to their lives. But, towards the end of the decade, the “second-hit” phenomena drove the pendulum in the other direction, according to Sanjeev Kothare, a practicing neurologist and epileptologist and director of the pediatric sleep program at the NYU Langone Medical Center. After incurring concussions, a number of teens died because they resumed activities before brain swelling subsided. They then suffered second concussions that, in their vulnerable states, proved fatal.
So, medical standards changed. Concussions became a big deal, and something for which doctors began to recommend lengthy rest and abstention from physically and cognitively demanding activities, including both sports and school work, until all symptoms disappeared. In some cases, kids put their lives on halt, and spent several weeks resting to heal.
In recent years, the focus on cautious recovery has only intensified, due in part to the cultural conversation surrounding football, among other high-impact, sports, and the troubling long-term consequences of common, seemingly minor head traumas. Through brain scans and, in some unfortunate cases, post-mortem analysis, doctors and scientists have connected sports injuries to mental illness, suicide, cognitive impairment and violent behavior.
But, a number of experts say we’ve gone too far with the “get rest” message. The study in question argues that, in waiting out every last symptom — including issues that can linger, such as headaches and dizziness — kids may face psychological consequences that could actually make their post-concussive symptoms last longer.
Study authors describe one patient, referred to as “ME,” who suffered a concussion in his sophomore year of high school during a wrestling match. ME reported his main symptom, a “non-debilitating headache,” to an athletic trainer, who told him to restrict his mental and physical activity and stay home from school for two weeks. Afterwards, per instructions from a concussion clinic, ME was told to stop exercising immediately if he experienced any one of a long list of postconcussive symptoms. He missed more school, the study says, because his mood declined. And, when he did resume vigorous exercise, he experienced headaches and dizziness, which were attributed to his initial concussion. ME then quit wrestling altogether over concerns about future concussions.
Researchers don’t, however, see ME’s residual health ailments as a product of his initial concussion. “In his case,” they wrote, "clinical management itself, including the implied messaging regarding the dangers of exertion, almost certainly contributed to his poor functional outcome.”
Cases like ME’s illustrate why, study authors believe, kids should go back to school, and even engage in low-impact exercise as soon as possible, avoiding only “high risk activities” that leave them vulnerable to re-injury.
Kothare agrees with the study’s conclusion, but bases his reasoning on a slightly different issue: sleep schedules. As smartphone-wielding night owls, Kothare points out, most teens already have wonky nighttime habits. They stay up too late on weeknights, struggle to wake up in the morning and sleep until mid-afternoon on the weekends. If they’re told not to return to school until their headaches disappear, what are they going to do? Obviously, camp out in front of the television, tap away on tablets and fire off snapchats. Forcibly rising for school is the only thing that keeps them on a vaguely normal schedule, and we should make every effort to maintain that structure.
“During their time off,” said Kothare of a common scenario he sees in teen patients who’ve had concussions, “their circadian rhythms get totally out of whack, and when they go back to school, they’re exhausted and have trouble paying attention in class, which sets off a vicious cycle of depression and anxiety and they just become a mess.”
Kothare has seen too many teen patients fall down rabbit holes sparked by medically-mandated breaks from school. “It’s very common, and many [patients] have been labeled as having chronic fatigue syndrome or fibromyalgia, but their problems all have to do with circadian rhythm desynchronization.”
Unlike the study authors, he's not concerned with kids quickly resuming exercise, but sees a swift return to school as a priority. Concussion patients should rest for 24-or-so hours, until nausea and vomiting cease, he says, and then avoid impact activities until the other symptoms simmer down, too.
Right now, however, the standard approach is still “rest it off.” But guidelines could change within as little as a year, Kothare says, if national pediatrics, neurology and sports medicine boards pen a shared letter in support of shorter recovery periods.