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Myth: ‘Cocoon Therapy’ Helps a Concussion

Two recent guidelines from U.S. and international experts have introduced new but subtle recommendations that undercut a style of treatment for sports concussion known as “cocoon therapy.”

Cocoon therapy shields children during concussion recovery from mental stimulation or physical activity. For the past decade or so, doctors adhering to this treatment advised parents to cover their children’s’ eyes with sunglasses, and isolate them in a dark room with minimal audio and visual cues—no reading or homework, no computers or texting, no email, social media, TVs or video games. The goal: to reduce demands on the brain at a time of decreased capacity and vulnerability.

Cocoon therapy grew out of the real concern that a “second impact” during contact sports could cause devastating harm to the brain of a child while recovering from concussion, when it is especially prone to injury. Experiments showing that physical activity slowed concussion recovery in animals led to further adoption of the approach, researchers have noted.

But studies in recent years suggested that cocoon therapy may not be helpful and could delay recovery. The recent guidelines, from the Centers for Disease Control and Prevention (U.S. 2018) and the 5th International consensus statement on concussion in sport (Berlin 2017), consolidated that research.

How long should children with concussions rest?

The U.S. and international guidelines offer similar recommendations. Neither proposes prolonged or complete rest or severe activity restriction.

Based on the best current evidence, they advise:

  • An initial period of mental and physical rest, described as “brief” or “within the first 3 days of injury” for children and adolescents. (For adults, the recommendation is one to two days.)
  • Avoiding rest beyond three days because more rest may cause symptoms to worsen or persist longer. “While rest in the first few days… may be beneficial, prolonged rest has not demonstrated any advantage,” according to a review by the international panel.
  • An early, gradual return to mental and physical activities (including return to school) that do not make symptoms worse or put children at risk for repeat concussions. Parents should monitor the number and severity of symptoms during this period.

What’s the basis for the advice?

Both groups say these recommendations represent best guesses. They don’t actually know the ideal period of time kids should rest after concussion. Nor do they know how vigorously kids should exercise as they gear up during recovery.

There is ample evidence that exercise is beneficial for children and adolescents. Exercise and sports help children develop strong muscles and bones, aid in the prevention of inactivity-related diseases such as diabetes, asthma and depression, and help improve social skills, focus, memory, attention and academic achievement.

Nevertheless, the research on the benefits of exercise in young athletes with concussion is imperfect and limited. A look at a few papers published between 2015 and 2018 help to explain how the current consensus evolved.

  • In a 2015 study, researchers enrolled 99 patients ages 11 to 22 who had concussions. They randomly assigned patients to (a) strict rest for five days; or (b) a program that consisted of one to two days of rest followed by gradually more demanding physical activity. After 10 days, there were no differences between groups in balance or tests measuring attention, memory, reaction time and other outcomes. However, the strict-rest group missed more school, had more symptoms and took longer to recover. “Strict rest added no benefit,” the researchers concluded.
  • A 2016 study in the Journal of the American Medical Association reported outcomes in 2,413 children and adolescents ages five to 17. Those who said they engaged in early physical activity within the first seven days after a concussion were significantly less likely to have symptoms 28 days later. The study has weaknesses, however. For example, patients rated their own activity levels, which may have led to inaccurate estimates. And it is possible that factors not measured by the researchers, such as symptoms of anxiety or depression, could have explained why those who exercised felt better.
  • Emerging evidence from patients whose symptoms persisted long after concussion suggests that controlled aerobic exercise on a treadmill may help to speed recovery if the exercise challenges the athlete but does not provoke symptoms.

Christopher Giza, M.D., a coauthor of both guidelines, tallied the problems caused by complete rest and cocoon therapy. “Prolonged absences from school, anxiety, depression, deconditioning, sleep disturbances, and other problems were increasingly seen as challenges in the recovery from [concussion],” he noted in a 2018 commentary.

“Activity is good for the growing brain,” he wrote. Although it makes sense to reduce stimulation in the immediate aftermath of a concussion, cocooning is not the answer.