Table of contents:
01:48 Resting your brain after sustaining a concussion
06:58 Active recovery for concussions
10:22 Concussion recovery is possible
16:43 Concussions and mental health
24:22 Compassionate concussion care
27:11 Concluding this Concussion Stories episode
Introduction to this episode on resting your brain after a concussion
“Rest your brain after sustaining a concussion”: that’s the advice that a lot of us still hear from doctors or believed to be common approach. But a lot of us are confused about it as well. Because we notice it doesn’t work, and even leaves us feeling worse than before. Where does this advice come from, and more importantly: what to do with it?
Professor Michael McCrea is an absolute authority on traumatic brain injury (concussions and post-concussion syndrome are traumatic brain injury). He shares from his experience and insight based on 2 massive American research projects involving both civilians and military service members.
Please keep in mind that a concussion is a so-called mild traumatic brain injury. Whenever we say “TBI”, this means traumatic brain injury.
[Melanie Wienhoven 00:00] Welcome to Concussion Stories, a Lifeyana podcast series filled with hope. I’m here to let you know that you are not alone in your concussion recovery. I’m Melanie and I spent more than six years experimenting, training and learning in order to heal myself from a very bad case of post-concussion syndrome.
And today, I feel better than ever before. In Concussion Stories, we dig deep while discussing hopeful stories of recovery as well as the hard stuff in the messy middle. If you’re struggling to focus, be sure to take breaks down in the description of each episode. You can find a table of contents in case you want to skip ahead. Let’s dive right in.
Professor Michael McCrea
Professor Michael McCrea is the embodiment of a busy bee. He is a clinical neuropsychologist and professor of neurosurgery and neurology at the Medical College of Wisconsin. Do you remember Center-TBI from multiple previous Concussion Stories episodes? It’s the massive European research group researching traumatic brain injury.
Professor McCrea is on a steering committee of Center-TBI’s equally massive sister projects in the US, Track-TBI – and he co-leads the Care Consortium, a huge American research project studying student athletes and military service members with a concussion.
All three studies, so Center-TBI, Track-TBI, and the Care Consortium are called the “studies of a generation”, as Professor McCrea will explain in this episode. And Professor McCrea himself is involved in two of them. So long story short: if you say concussion or post-concussion syndrome, you say Professor McCrea. Let’s listen to all that he has to share with us.
Resting your brain after concussion
Before we started this recording, we already talked a bit about my experiences, and you shared something very interesting about the advice of rest. Maybe you could share a little bit about it with our listeners as well?
Twist and turns in concussion protocols
[Professor McCrea 02:07] Absolutely. So, we’ve taken many twists and turns, I would say, in our approach to acute management and rehabilitation and return to activity after concussion. Whether that be in our civilian patients in the hospital or clinic, with our athletes affected by sport-related concussion, or in military service members who are injured in the line of duty.
And the common thread to all three of those populations who we know are at risk of mild traumatic brain injury or concussion, it’s the ultimate goal of returning to our former activities. So we started developing protocols for a graded exertion: rest followed by graded exertion.
And even the concept of rest was something that was debated and argued. Is it necessary at all? In a sports setting, for instance, it was very common for athletes to return to play in the same contest many, many, many years ago. Thankfully, that’s no longer common practice.
Complete stimulus deprivation
So, some were arguing that rest was really not important at all. And at the other end of the continuum, there were people out there arguing for the need and benefit of complete and total rest, meaning physical and cognitive rest.
That really even eventuated to the absurd notion that it would be best for a person affected by concussion to be in a dark room with the lights off and without access to their device. Or we don’t want you reading magazines or answering the phone. Complete and total rest – or what was even in some instances called cocoon therapy: complete stimulus deprivation.
Complete rest does harm
And we know from preclinical studies in animals that that approach was definitely not supported by the evidence. Some would argue that it was at risk of even doing more harm than good. And then we started to see in our patients – again, common people off the street or athletes or military service members – that this notion of complete rest was really doing more harm than good physiologically and psychologically.
So, in the setting of sports for instance, you’re taking a population that is arguably the most active group of people on the planet. And we’re telling them: listen, we don’t want you to do anything, you might harm yourself.
We would have parents of young athletes come into the clinic and we’d ask them: has your son or daughter started to do any light exercise yet? And they look at us appalled and say: we didn’t want him to get out of bed, because we were worried it would do brain damage.
The misinformation out there for our patients and their families was really a challenge to overcome, because there was this belief that if people lifted a finger, they would potentially do harm to themselves.
Rehab starts today
Really, there is no medical condition on the planet in which complete and total rest is the therapeutic pathway. Really, a striking example is that if you have multiple cardiac bypass surgery this morning this afternoon, they’re going to have you up walking the hall. Your rehab starts today.
And so we began to realize from both the evidence and our observation of our patients, this was more about turning the brain on than turning it off. When ready.
Active recovery for concussions
You know, I think common practice after a concussion is maybe a couple of days of rest or really laying low, as we call it. And then gradually introducing low intensity, short duration exercise that we know is beneficial from a therapeutic standpoint. But that’s also immensely helpful in terms of psychological adjustment to injury and recovery. So that’s really what drives modern day approaches to active rehabilitation.
[Melanie Wienhoven 07:33] Thank you for that whole overview of where everything came from and how it came to be.
[Professor McCrea 07:38] I’m sorry. You lit a spark and I got a little carried away.
Understanding the advice of rest
[Melanie Wienhoven 07:42] No, you don’t have to say sorry, it’s really, really helpful. Because I have an overview right now, after I’ve gone through everything. But while I was in the middle of it, I couldn’t understand.
At first, I couldn’t understand what was happening to me. I couldn’t understand the whole field and everything that was being said to me, as well. And only after I went through everything, I got to see this history of medical advice. How it came to be and why I was advised to rest so often. Or why I was being told that my brain injury would never recover, because it had been taking too long. And that’s something that I hope a lot of people will get from your spark just now.
Even doctors get frustrated
[Professor McCrea 08:34] I think sometimes in clinical practice, we see that if our patient is not recovering at the pace at which we would like to see them recovery or we would expect them to recover based on condition A, whether that be concussion or some other form of injury or illness, even clinicians then get frustrated.
And the longer that extends in its phase, the less energy clinicians often want to put into that patient. It’s really a shame that the patient starts to feel like they got tossed aside because they’re no longer that good student or are following that course of recovery that everyone predicted.
[Melanie Wienhoven 09:24] Yeah, that’s indeed the feeling that I had almost right from the start. After two weeks already, I failed the perfect A student test, and I was already feeling like I was doing something wrong – because I should have recovered.
Stress and concussion symptoms mix
[Professor McCrea 09:47] And that contributes to your stress level. And pretty soon what often happens in cases of persisting symptoms is: it’s hard to tell where my concussion left off, and my stress takes over. The symptoms of each can look very much the same. And then it’s a little maddening. As I’m trying to determine for myself: is this my concussion talking? Or is this my stress talking?
Concussion recovery is possible
[Melanie Wienhoven 10:22] Yeah, it is. You’re recognized a lot I can hear. You’re not an expert by experience, but you’re also an expert by experience, because you’ve probably seen a lot of concussion patients, right?
[Professor McCrea 10:36] I’ve seen a few. I’ve seen a lot over a period of almost 30 years. Thankfully, the prognosis is highly favorable for a complete recovery after an injury like this.
[Melanie Wienhoven 10:50] It’s so wonderful to hear you speak those words. I know, but it’s not what a lot of people know. Especially not those going through it.
Hope for complete recovery
So, if I say: there is hope for complete recovery for people with a concussion, you say?
[Professor McCrea 11:09] 100%. Yes, you are. And these are words of encouragement, that it’s good for anyone to hear clinicians and patients and families alike.
Unfortunately, a high percentage of patients with concussion or mild traumatic brain injury may have no medical contact at all. And they’re left wondering: what’s going on with me? And then anxiety starts to really play a driving role.
Insufficient concussion care
Or they may be treated and released at an emergency department or a clinic and have no follow up whatsoever. I was part of a recent committee here in the US sponsored by the Department of Defense and executed by the National Academies of Sciences, Engineering, and Medicine.
Our report was released just a couple of weeks ago and one of the main take home messages of that report is that we really lack an adequate and robust system of care for traumatic brain injury, whether that be in hospital or even more so in an outpatient ambulatory setting.
Patients are often left to sort of fend for themselves in finding a specialist to see. They do not have any follow up whatsoever to assess their recovery and then clear them to return to normal activity or guide their rehabilitation.
Track-TBI and the Care Consortium
[Melanie Wienhoven 12:43] Yeah. These findings that you just mentioned are completely similar to what Center-TBI in Europe has found as well. You are involved with the project…?
[Professor McCrea 12:57] With Track-TBI and also something called the Care Consortium, which is sort of a parallel to Track-TBI in the US and Center-TBI in Europe. Those two studies are focused on civilian traumatic brain injury. The Care Consortium here in the US is a large-scale national study of concussion in athletes, collegiate athletes and military service academy members.
Better concussion care for TBI patients
[Melanie Wienhoven 13:25] Okay. Well, it’s very interesting, as Andrew Maas also mentioned in one of our previous Concussion Stories episodes, that if in Europe we find things, and over in the US you find things and those things are similar… Then at once we have a whole lot of evidence that the system, in fact, should change in a specific direction, right? That’s very impactful.
[Professor McCrea 13:54] Correct, and probably not definitely confined to just Europe and the US. I mean, we’re finding similar patterns in the common causes and characteristics of TBI, the natural history of recovery and long-term outcome. And they are really important observations as it relates to the need for, again, a more robust system of care for patients affected by traumatic brain injury. It’s sort of a universal finding around the globe.
Concussion protocols will change, too
[Melanie Wienhoven 14:34] Yeah, it’s so important. I’m so thankful that it is happening, because it’s on such a large scale that eventually in a few years, things will change. An awareness will come, but also hopefully protocols will reach all of those GPs and neurologists who still are now giving advice that rest probably is best. Because they don’t have an idea about all of those new findings.
[Professor McCrea 15:05] That’s right.
[Melanie Wienhoven 15:06] That’s the most important thing.
Research takes time to conclude
[Professor McCrea 15:08] And like in all areas of science and medical research, you know, observations or case studies are sort of… I use the term around here that they’re the seedlings on which the scientific method is grown. But it takes a while for science to catch up and conduct the research necessary to answer critical questions.
Studies of a generation
I love it – I’ve heard people refer to the Center-TBI effort, the Track-TBI effort and then the Care Consortium… These are three really massive, large-scale national studies that I’ve heard people refer to as the “studies of a generation” in their scope, their size, their depth, and ultimately the impact they will have on both the science and, and clinical practice and policy.
I mean, that’s the reason we all get into this work in the first place: to have some impact at the bedside, in the clinic. These are not just science projects, these are ultimately intended to change how we practice medicine, in a way that improves the recovery and outcome for our patients. It has a real-life impact.
Concussions and mental health
[Melanie Wienhoven 16:43] It has… It really has. You have already acknowledged, while we were talking without recording before, the huge psychological effect that a concussion may have on someone’s life. Especially if, consequently, the advice has been given to rest and isolate yourself from everything that you used to do. Can you tell us a little bit more about that?
Cocoon therapy is harmful
[Professor McCrea 17:11] Well, yes. So, as I mentioned earlier, we have and hopefully all providers around the globe have moved beyond this notion of cocoon therapy or total rest. Rest is clearly not the indicated approach for rehabilitation and return to activity after concussion, and the evidence bears that out.
Shaping active recovery
We’re really moving in the other direction now: understanding the safety and efficacy of sort of the reverse of rest – activity. So how do we prescribe activity? What type? How much, how long? How intense? How frequent? Just as we would shape any form of therapy.
And that has to be approached in terms of understanding the safety: how much is too much? How much is therapeutic without putting a patient at risk of a setback? And then the efficacy: which approaches work best relative to our current approach of brief rest and graduated exertion?
Educating medical professionals
This is more about educating healthcare providers than it is public themselves. Because ultimately, it’s really the responsibility of individual providers to be aware of the evidence base and how that informs my approach to clinical practice.
[Melanie Wienhoven 19:13] Yeah, I believe so too. And surely it is about increasing activity, like graded activity and also active recovery: that’s one of the keywords of everything I teach others. But also, one thing that I noticed no caregiver ever talking to me about, is about the psychological consequences of a concussion.
Mental health effects of isolation
[Professor McCrea 19:30] You know, sometimes these things are right in front of us and we can’t see them. I’ll take this to the absurd. Let’s say I approach someone who has not had a concussion and I say: listen, for the next five days, I don’t want you doing anything.
I want you to go home, not reading, not engaging in social activities. Not leaving the house, no physical activity, no television, no music. I want you in a complete and total rest mode for the next five days.
This is someone without a brain injury. What kind of shape do you think they’re gonna be in five days later? They’ll probably be climbing the walls. They’ll feel lethargic without physical activity or motion, they will probably be stressed to the hilt by anxiety. And again, this is someone without a brain injury.
Total rest is counterproductive
So, the notion that we were advising people with concussion… Again, there’s some apologies here, because there really wasn’t the abundance of data available 10 or 15 years ago like there is now, advising us on our approach.
But just the notion that we were advising people with brain injury to remain under complete and total rest was counterproductive from a physiological standpoint, in terms of promoting brain health and recovery. But it also had major psychological fallout where people began to become more and more anxious and depressed, more isolated, withdrawn.
And all of a sudden, we had a bigger problem than just the concussion that we had to undo. I saw it again and again in our patients; I saw it affecting parents. It really became a significant and pervasive problem.
[Melanie Wienhoven 21:57] And it’s something that I would like all caretakers to be aware of if any are listening. Because it’s so important to see the human side of a concussion or any traumatic brain injury for that matter as well. Concussion still is called the mild one, even though we know it’s not so mild anymore.
[Professor McCrea 22:19] That’s right.
[Melanie Wienhoven 22:20] Yeah. Those are the words of Andrew Maas by the way, I’m quoting him.
Beyond medical protocols
But it’s so important to see those human aspects, aside from only the medical part, and even though I know that the field is changing and different advice is being given more and more, most people who come and find me still are being advised to rest.
And I think those are the people that find me, because it’s my message as well. It’s the thing that I heard the most. But the advice is still being given. And it’s so important for us to change. And I believe your research will help with that as well.
[Professor McCrea 23:20] We all have an obligation to, you know, correct untruths – or whatever they might be. For not only patients but also for providers out there who have been the recipients of misinformation or bad advice.
[Melanie Wienhoven 23:40] If you look deeply into it, it’s all very understandable, right? It isn’t like they’re made the mistakes on purpose. We just have a lot of education to do. Research really has started only recently, if you look at the long period of time that you have been working on concussions. It’s only for the last 10 years that you see this real increase in research on brain injury.
[Professor McCrea 24:00] You could make the argument, I think, that maybe more progress has been realized in the last 20 years certainly than any other time in history, as it relates to scientific discovery and breakthroughs in real translational research in traumatic brain injury. It’s been really quite amazing.
Compassionate concussion care
[Melanie Wienhoven 24:22] Yes, it has. So, I have one more question for you. Because on your personal page on the Medical College of Wisconsin website, you write that you find it so important to show compassion with your patients as if they were your own family and also to involve family members. I see you’re laughing as a response, why?
Ground truth for patients
[Professor McCrea 24:49] I’m laughing because I had a discussion with a patient and their spouse this morning about a very unfortunate situation. This is not a concussion patient. I literally found myself saying the words that “if this were me or my spouse, here’s what I would do”.
And I think, when you can be honest with your patients, they are much more likely to instill their trust in you. And sometimes we encounter patients who are in very difficult situations based on a new diagnosis, for instance, that can be very serious and have major consequences.
That’s where they want ground truth, and there’s no more ground truth in my experience than me saying that “if this were me, or this, were my wife, or a family member, here’s what I would do”. When the chips are down, this is the decision I would make.
Open and human advice
And they’re certainly entitled to go get another opinion. But you’re being completely honest and forthright with them, and nothing’s more important than that in my mind.
[Melanie Wienhoven 26:29] I agree.
[Professor McCrea 26:30] We all deserve that, right?
[Melanie Wienhoven 26:32] Yes, we do. And I also believe that that is the position that could give advice like: I don’t know, but maybe you should find your answer here and here. That’s something that’s missing a lot in concussion.
[Professor McCrea 26:51] Correct.
[Melanie Wienhoven 26:51] That would help, I believe.
Encourage second opinions
[Professor McCrea 26:53] We don’t have the answers here, but we have access. We’d like you to go see this person, this specialist, who we are confident can provide you the help you need.
[Melanie Wienhoven 27:04] Yeah, I think that’s the best attitude you can have as a medical professional.
[Professor McCrea 27:10] For sure.
Concluding this Concussion Stories episode
[Melanie Wienhoven 27:11] I want to thank you for your time with me, because you’ve already shared so much and you’re very busy, as we’ve already discussed. Maybe we’ll see each other in Amsterdam in October, I don’t know if you will be joining?
International Consensus Conference on Concussion in Sport
[Professor McCrea 27:24] I am planning to attend the International Consensus Meeting, yes. It’s always a great meeting. And God willing will, we’ll be able to keep it on the schedule. Let’s hope things improve on all fronts for all people, and that we’d have the opportunity to host that meeting this fall.
Thanking Professor McCrea
[Melanie Wienhoven 27:47] Thank you very much for your time, and your expertise, and also your compassion, because I saw a lot of that.
[Professor McCrea 27:55] You’re welcome. Thanks for hosting me. I enjoyed it a great deal.
Now I’d love to hear from you
[Melanie Wienhoven 28:00] Now I would love to hear from you. What do you take away from this episode? Is there something that you can apply to your life right away? Head on over to Lifeyana.com and leave your comment now.
And if you want to hear and read more Concussion Stories, actionable steps and inspiration, be sure to subscribe to the Lifeyana email list while you’re there, so that you never miss out on new materials we constantly make for you. If you want to support this podcast, head on over to patreon.com/concussionstories.
Thank you for listening to this Concussion Stories episode by Lifeyana. May you be well, and may you be happy.