There’s been a lot of talk about concussions recently.

The National Football League will hang posters in all team locker rooms this season describing the risks of head injury.

In Oregon, a new law requires coaches to be trained in concussion recognition and players to sit out until they get a medical release. At least 10 other states now have similar rules.

For all the increased attention, experts say one major piece has been missing. Most of the talk has focused on sitting out from practices and games, with the idea that physical activity might hamper recovery or risk a re-injury.

That’s true. But emerging research suggests that a break from cognitive activity, the thinking that most of us do at school or work, could be just as important. Cognitive rest, as it’s known, could be key to recovering from concussion.

“These students not only need to miss football, they need to miss algebra as well,” said Dr. Tom Carlsen, a retired surgeon and sports medicine specialist in Bend who, for years, treated local athletes for concussion.

While concussion management programs have sprung up in many communities, including here in Central Oregon, experts say that by not including a cognitive rest piece, they may be missing a crucial element. Most times kids are required to miss practice but can go back to school almost immediately after a concussion.

“The laws are all about sports, return to play,” said Dr. Micky Collins, a neuropsychologist and director of the sports medicine concussion program at the University of Pittsburgh Medical Center.

“I think that’s important, but I think that there’s more to it than just return to sports. There is a whole other level of management that needs to happen,” Collins continued.

Still, getting athletes to stay away from their sports is hard enough. With the new restrictions, experts worry that they’ll have an even harder time convincing parents, coaches and teachers that kids can’t just push through.

Previously “you shook it off,” said Carlsen. Today, “it’s a new paradigm.”

An energy crisis

Jake Lasken was a senior last year, playing for the Sisters High School varsity soccer team. During a game, he was going for the ball just as two other guys were also chasing it. The three crashed.

“He was totally knocked out,” said his father, Glen Lasken. He regained consciousness quickly and walked off the field on his own, but still wasn’t well. He had problems with balance and memory that night, his father said, and went to St. Charles Bend’s emergency room.

Lasken spent the night in St. Charles and didn’t go back to full practice for more than a month.

Concussions like Lasken’s can happen in impact sports like football or soccer.

Inside the skull, there is room for the brain to move around. Cushioned by fluid and soft tissue, the brain has some protection from a blow to the head or a sudden stop, as when the head hits something hard.

But there’s a limit to how much give is in that buffer. Too hard a blow or too forceful a crash can send the brain slamming into the skull. That is a concussion.

When a person suffers a concussion, a host of changes take place in the brain’s chemistry.

To begin, the force of the injury causes brain cells, called neurons, to act erratically. Neurons typically communicate with one another by releasing different combinations of chemicals. A concussion jars the neurons, and they release a strange brew of chemicals that increases the brain’s demand for energy at the same time it clamps down on the blood vessels that supply oxygen-rich blood that would bring that energy.

“What a concussion is, is really an energy crisis,” said Collins. “It’s not enough to kill the (brain) cell, but it’s enough to make it more vulnerable.”

The chemical imbalance also causes the neurons to have difficulty communicating with one another. People with concussions often report that they cannot think as well as they normally do. This is, quite literally, because those brain cells that they would use are having trouble getting messages through.

“We think the neurotransmission is going at 30 miles per hour instead of 60 miles per hour,” said Gerald Gioia, director of neuropsychology at Children’s National Medical Center in Washington, D.C., who has done a good deal of research on cognitive rest. That’s why, Gioia said, going back to cognitive tasks that tax the brain can hamper recovery.

“If you start to ask (the brain) to work too quickly, you are pushing on a bruise,” he said. “You are asking more of the brain than it can physiologically deliver.”

Recovery time

Even though the impact is sudden, the chemical imbalance that results from a concussion can take hours to develop, said Gioia. That’s why athletes will sometimes say they feel fine right after a rough hit only to fall ill later.

Recovery depends on the severity of the impact and often takes weeks. The brain needs to reset itself and to restore the normal chemistry that allows it to function well.

“Recovery at a very simple level is the brain’s cellular structure returning to balance,” said Gioia. “What we know is that the brain will do that. And what we also know is that if we don’t manage the process of that recovery carefully, we will delay it.”

Much of the work around concussions during the past decade has been on understanding what happens in the brain and how to best help it recover. The science that allows clinicians to do that is just now emerging thanks to greater public awareness of the dangers of head injuries.

“There’s been a significant emphasis on head injuries in the past five years,” said Carlsen. “So what’s going to be learned in the next 10 years will dwarf what was learned in the last hundred.”

The guidelines are constantly changing, even on a local level. Last year, after his concussion, Lasken went back to school almost immediately, said his father. He had trouble concentrating there, his father said, and went to the nurse’s office. She sent him home early. It took Lasken more than a month to get back to all activities, his father said, though eventually he did make a full recovery.

As evidence emerges of the importance of cognitive rest, it will filter down to clinical guidelines and likely govern when kids go back to school, said Carlsen.

Currently, because the science is so new, there are no rules. How quickly they go back to school depends on their individual circumstances, including the severity of symptoms and how strenuous their school schedule is, said Sondra Marshall, a neuropsychologist at St. Charles Bend. Students like Lasken still go back to the classroom long before they go back on the field.

But here, and in other places, that’s beginning to change. “We need to give kids a medical release from the classroom,” said Leah Schock, another neuropsychologist at St. Charles Bend who, along with Marshall, sees many of the local athletes who suffer concussions.

Gioia, who sees patients in the Washington area, said he tries to get injured kids focused on taking time out from everything: sports, school and anything else that taxes the brain. Gioia said even too much emotion, also regulated by the activity of brain cells, can hinder recovery from concussion.

“Kids that are very anxious, very scared, very sad, they recover more slowly as well,” he said. When he speaks with kids – and it’s often the high-achieving ones that have the most problems, he said – he tries to get them to relax. He tells them, “you’ve got to accept the fact that I’m cutting you a break. The more you worry and the more you over-focus, it’s probably an overuse of the brain.”

Need for education

When Lasken suffered a concussion last year, his father said one of the hardest parts was getting him to accept that he needed to slow down a bit. He had to miss a class trip, backpacking into the high country near Sisters. “That was heartbreaking,” his father said.

Lasken’s experience is echoed, clinicians say, by many parents and students with concussions. They are not used to being out of the action and have a hard time accepting that they just need to slow down for a while.

“It’s not so simple to just tell a kid to sit in the corner and not do anything,” said Gioia. “As a clinician, I feel like I’m putting handcuffs on these kids.”

Gioia said he relies on the support and understanding of adults around the kids — parents, teachers and coaches — to remind kids to take it easy. With a concussion, kids need as much rest as possible, Gioia said.

Experts say that kids can do activities that avoid taxing the brain — reading easy books and magazines or watching TV — but should avoid things that require deep thinking. If symptoms such as headache, dizziness and fatigue come on, a person should stop doing the activity and rest.

But even getting buy-in from parents and coaches can be tough.

“Parents think, ‘My kids can’t play (sports), but they can text and they can play video games and they can drive,’” said Marshall. Recovering from a concussion, she said, “is so much more challenging.”

Schock said that since she and Marshall began practicing in Central Oregon several years ago, they have seen a change in the attitudes of parents and athletic trainers. In addition to evaluating and treating concussions, she said, a big part of their job has been educating parents, trainers, coaches and anyone else that concussions will go away only when the brain rests.

The old way, said Schock, is not effective. “There’s a tendency for athletes to just push themselves through the pain. That doesn’t work with concussion.”