Concussion Management We are writing in response to the piece in the December ASHA Leader by Kathryn Hardin (“Coming Out of the Dark,”) which proposes a “new” perspective on concussion management. We appreciate Ms. Hardin’s efforts, but must take exception with some of the statements that were made. The premise that traditional ... Inbox
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Inbox  |   February 01, 2016
Concussion Management
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Attention, Memory & Executive Functions / Traumatic Brain Injury / Inbox
Inbox   |   February 01, 2016
Concussion Management
The ASHA Leader, February 2016, Vol. 21, 4. doi:10.1044/leader.IN1.21022016.4
The ASHA Leader, February 2016, Vol. 21, 4. doi:10.1044/leader.IN1.21022016.4
We are writing in response to the piece in the December ASHA Leader by Kathryn Hardin (“Coming Out of the Dark,”) which proposes a “new” perspective on concussion management. We appreciate Ms. Hardin’s efforts, but must take exception with some of the statements that were made.
The premise that traditional concussion management means that all individuals with concussion have been remanded to dark rooms for extended periods of rest with no external stimulation is not correct. There is abundant clinical evidence that indicates that a period of rest post-injury is indicated. The modulated restriction of visual stimuli such as the flickering screens of computers or televisions is based on feedback from the client regarding exacerbation of symptoms. Similarly, the literature clearly supports a stepwise return to cognitive, academic and physical activity based on physiological improvement and symptom experiences. The accepted standard of care has not been proven to be inadequate or worse, iatrogenic. Further, the study cited by Hardin as a landmark in this area should be reviewed on its own merits to determine whether the conclusions presented here are supported; we think not.
While it appears that Hardin’s article endorses this proposed revolutionary methodology of rehabilitation, in this particular circumstance, the preponderance of clinical evidence does not support the claims being made. As practicing clinicians and researchers, we are required to let the evidence guide our practice and, when there is insufficient data, to let caution be our guide.
Bess Sirmon-Taylor, El Paso, Texas; Anthony P. Salvatore, Santa Teresa, New Mexico
Kathryn Hardin responds:
I am pleased this article generated discussion. Consideration of the statements by Professors Sirmon-Taylor and Salvatore is important.
The article did not state “all individuals” engage in darkroom therapies, but rather that this was a historical practice. Many have shifted from this model and what Elizabeth Wells and colleagues call its “significant public health consequences” (Journal of Child Neurology). Similarly, it did not argue against gradual return to activity—it advised creating a scheduled plan. The crux of the article advocates active support.
The professors assert “an abundance of clinical evidence” for cognitive rest. For my practice, that remains insufficient. The American Academy of Neurology and the National Athletic Trainers’ Association report lack of evidence regarding cognitive rest, as Gary McAbee reports in the Journal of Child Neurology. Neil Craton and Oliver Leslie, in the Clinical Journal of Sport Medicine, say the Zurich rest parameters “are not evidence-based … and cannot be endorsed.” The article did not discourage all rest, but rather shortening its duration. Danny Thomas and colleagues’ 2015 study in Pediatrics is the only Level I evidence on cognitive rest post-acute concussion. I encourage all professionals to gauge its merit.
Regarding iatrogenesis, a recent Clinical Pediatrics article by Mark DiFazio and colleagues encapsulates why ongoing rest can contribute to post-concussive symptoms—and how clinical guidelines should modify this recommendation.
It can be challenging to recalibrate clinical practice, faced with evolving evidence. Personally, I have found active rehabilitation to be empowering and effective for clients post-concussion.
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February 2016
Volume 21, Issue 2