How We Got Concussions So Wrong

I got a concussion. I didn’t get better. It turned out even my doctors had bought into a powerful myth.

The first time Conor Gormally got a concussion, he felt as if he were standing on a ship at sea. A high school soccer player, he had decided to try out something new during his off-season: wrestling. His very first opponent caught him off guard, with a headbutt to the temple. “I stood up, then my horizon tilted to a 40-degree angle and I fell to the ground,” Gormally told me years later. He felt the room tip and roll. Emotions welled up from out of nowhere. “I was sobbing and saying, ‘I don’t know why I’m crying. I’m not upset. I’m just confused. I don’t know what’s happening here,’ ” Gormally recalled.

After examining Gormally, the school athletic trainer told him to go home and rest. Gormally’s primary care provider said the same thing, adding that he shouldn’t return to school or practice until his symptoms resolved.

Gormally dutifully followed their advice. He turned off the lights in his room, drew the curtains, climbed into bed, and rested. And rested. And rested. Weeks passed. The fall semester ended. Gormally still wasn’t better. He was exhausted and had a headache around the clock. His emotions continued to be all over the place. One moment, he would feel totally numb; the next, he would get overwhelmed and start crying. He tried going to a movie with his mom and girlfriend. The sounds and lights were an assault—he went home nauseated, with a pounding head. Wasn’t the rest supposed to be helping?

When Gormally visited his primary care provider a second time, the doctor told him to just keep resting. The doctor wrote in the appointment notes, which Gormally later requested, that Gormally was “frustrated” and his mother was “overbearing” and “overly worried.” After almost two months, Gormally was finally well enough to go back to school—and ready to put the whole experience behind him. But he kept getting concussions. Three more times over the next three years, he hit his head playing sports: twice in soccer, and once during Ultimate Frisbee. With each concussion, he received the same spiel from medical providers: “There’s not much we can do for you.” “Go home and rest.” “These things tend to get better on their own.” Each time, it didn’t feel as if they did.

There was a reason the “just rest” advice worked so poorly for him. For years, doctors had been told that concussion patients needed total rest in order to recover. But around the time of Gormally’s concussions, which occurred between 2013 and 2016, the science was beginning to indicate the opposite—patients who “cocooned” themselves in a dark room, even for only a few days, consistently took longer to get better than people who stayed engaged with their daily activities.

Since then, study after study has shown that the concussed brain requires active rehabilitation—activities like exercise, reading, and screens—to heal. The most up-to-date Consensus Statement on Concussion in Sport, a report prepared by an international panel of experts, recommends “active rehabilitation” and discourages total rest. As with most injuries, the specifics of what that rehabilitation looks like varies from case to case; researchers and specialists have an arsenal of protocols and therapies at their disposal.

You’d think that this would have meant a revolution in how doctors understand and treat concussions. It hasn’t. For many patients, not much has changed at all. A report published in 2018 found that more than half of patients with concussions—millions a year in the United States, according to the Centers for Disease Control and Prevention—are still leaving the doctor’s office without actionable, evidence-based information or referrals to specialists. Instead of that crucial step, many patients, to their detriment, are still being told to simply cocoon. That’s the advice I got last May. During a pickup game of soccer, a ball slammed into my head, shattering my sunglasses and giving me the immediate feeling that everything around me was happening in 2D. Over the following days, then weeks, everything felt gauzy and sore. My normally chatty internal monologue was quiet. I had a constant feeling of pressure behind my eyes. Cooking, reading, and cleaning may as well have been linear algebra.

No fewer than three medical professionals told me that a concussion was a “bruise to the brain” and that I needed to rest as much as possible for it to heal. Their definitions of rest were all slightly different, from blinds-drawn sensory deprivation to short walks. But all told me that if my symptoms got any worse, I needed to immediately stop whatever I was doing—otherwise, I risked drawing out my recovery.

“It’s a huge myth,” Gormally told me. In 2018, after his experience, he and his mom founded Concussion Alliance, a nonprofit that is dedicated to patient and provider education. “It’s so pervasive; it’s actively damaging people’s recovery.” The idea that cocooning may be harmful is completely new information to most patients Gormally meets. Concussion experts I spoke to say it’s probably not a coincidence that half of concussion patients continue to experience symptoms months after the initial hit.

That was me. It was four months after my concussion—months in which I lost income and watched, from bed, as my summer slid away—before I could say I was mostly recovered. The way I ended up with the information I needed to heal felt like sheer luck. In the aftermath, I was still reeling. I wanted to understand: How did we get concussions so wrong in the first place? And how many patients were still being told the wrong thing?

As long as humans have been hunting and gathering, playing and fighting, we’ve been bonking our heads. But until the 1990s, we treated these bonks—the ones that do not outwardly appear to damage anything—as if they were no big deal. “No one recognized that concussions were dangerous. We just sent people back onto the field, or into a war zone,” said Mary Alexis Iaccarino, a physiatrist specializing in concussion recovery at the Massachusetts General Hospital Youth Sport Concussion Clinic. Athletes were allowed to accumulate hit after hit; workers were expected to be on their feet all day while their heads were still swimming. “That was bad,” said Iaccarino. “That is still bad.”

It’s largely because of football that we’ve started clocking how life-altering concussions can be. Throughout the 20 th century, there had been isolated reports of athletes developing a constellation of disabling symptoms: depression, mood swings, rage, drug addiction, and memory problems. The first mention of the disease, published in JAMA in 1928, labeled it “punch drunk syndrome.” By the 1990s, amid growing concern about concussions and their extended impacts, the NCAA and NFL began funding long-term research into the epidemic.

The 2002 death of NFL Hall of Famer Mike Webster, who had suffered a lengthy cognitive decline, brought concussions into the spotlight. When neuropathologist Bennet Omalu conducted Webster’s autopsy, he discovered tangles of proteins dislodged from Webster’s brain cells by thousands of hits. Autopsies of dozens of other players revealed the same phenomenon. He called the condition chronic traumatic encephalopathy.

It’s worth mentioning that CTE is vanishingly rare, even among athletes. But the disease’s discovery and the epidemic of postconcussion symptoms among football players helped usher in a drastic change in the way we treat concussions generally. Instead of hustling people back out onto the field, doctors began pushing rest. Between 1999 and 2001, high school and college football players were returning to the field just three days, on average, after getting a concussion, according to an analysis published in the British Journal of Sports Medicine. By 2014, they were waiting 13 days. Studies showed that rats with brain injuries performed worse in cognitive tasks and produced less of a protein important for brain healing when they were forced to run on a wheel vs. when they were allowed to do whatever they wanted, whether that was exercising or just chilling out. Other studies showed that humans tended to feel better if they didn’t immediately return to work after a concussion.

It’s one thing to avoid immediately going back onto a football field, where you might get hit again before you’ve recovered, or to work, which might be cognitively straining. But instead of nuanced advice that included downtime or a scaling back of activities, the recommendation became total rest. In 2009 the third Consensus on Concussion in Sport listed “complete physical and cognitive rest until symptoms resolve” as the first line of treatment for a concussion. Doctors began telling patients to draw their blinds, close their eyes, and return to their lives only when they felt better. “We swung the pendulum completely in the other direction,” Iaccarino said.

Immediately after a person gets a concussion, resting in a quiet, dim place can feel good—and for some individuals, a day or two of this might be helpful for recovery. Then there’s the tendency to conflate concussions, which are considered mild traumatic brain injuries, with more severe conditions, like penetrating head injuries or brain hemorrhages. In those cases, many patients benefit from a very quiet environment. “We were trying to apply concepts globally, and it may not have been the right thing,” Iaccarino said. The days immediately after my concussion weren’t too bad. It was a long weekend, so I hadn’t had a chance to speak with a doctor. I went home and slept for a few hours, then walked to the grocery store. I slept some more. I went on a first date, where I ordered a virgin piña colada. Then I took a nap. Sure, I was exhausted, and the summer sunlight was painful when I didn’t wear shades, but I figured I was taking a path of moderation. On Monday, I was getting ready to start work when I thought to call a physician. On that phone call, I was told that I had been going about my recovery all wrong—I needed to be in bed. So I put my phone away, turned on some calming instrumental music, and lay down. That’s how I stayed for the next month.

We think of concussions—partly because doctors say it so often—as a “bruise to the brain.” But that’s not quite right. It doesn’t capture the cascade of changes that happen inside the skull during and in the aftermath of a blow to the head. Imagine this instead. Your brain is Jell-O sitting inside a mold: your skull, with a viscous layer of cerebrospinal fluid holding it in place. If that Jell-O shakes, it doesn’t slosh. On the inside, it’s twisting back and forth. “It deforms,” said Christina Master, a pediatric sports medicine and brain injury doctor at Children’s Hospital of Philadelphia who specializes in concussions. As your brain jiggles and twists, neurons—the long, cordlike cells that transmit signals in the brain—stretch and fray.

Without those pathways, communication within the brain becomes chaotic. You might open your email and see a scramble of words, struggle to organize the steps in a recipe, or try to jog only to forget where your limbs are in space. “The regions of the brain aren’t talking to each other properly,” said Fatima Nasrallah, a neuroscientist at Queensland Brain Institute in Australia. These neurons are terrible at repairing themselves, said Henrik Zetterberg, a professor of neurochemistry at the University of Gothenburg in Sweden. But it turns out that to heal from a concussion, your brain doesn’t actually need to stitch together those damaged connections. When a major highway needs roadwork, commuters don’t just wait around until it’s complete. Instead, traffic gets diverted. That’s what happens after a concussion, Zetterberg said. When brain cells stretch and fray, signals get sent down other neural pathways. At first, this is incredibly taxing. You might feel exhausted, have pounding headaches, and be emotionally frazzled. You might struggle to complete tasks that once felt easy, like reading or doing basic math. Then, eventually, you might start to feel better. “That is not because the brain has healed,” Zetterberg said. “It is because the brain circuits that are not injured, they recalibrate themselves.” The brain finds new highways to send signals down.

Total rest—the kind where you’re lying in bed all day, doing nothing—generally isn’t good for the body or the mind.

During that recalibration period, you may have to go easier on yourself. But that recalibration can’t happen while you’re lying in bed in a dim, quiet room. Total rest—the kind where you’re lying in bed all day, doing nothing—generally isn’t good for the body or the mind. People on bed rest lose muscle mass, have a slowed-down metabolism, and become dehydrated. This protocol can even delay recovery in patients critically ill from heart disease or suffering from rheumatoid arthritis. Concussion patients aren’t told to just rest in bed—they’re often encouraged to go through a period of sensory deprivation. “In a lot of places, that’s torture,” Iaccarino said. “It induces things like depression, light sensitivity, noise sensitivity, physical deconditioning.”

The recognition that total rest is detrimental to so many other conditions made researchers start to question whether it was truly helping concussion patients. But the medical world has been slow to catch up. Four weeks into my concussion recovery, my routine hadn’t changed much. Each day, I woke up, drank my coffee, ambled the half-mile around the pond near my house, then lay down and listened to two episodes of the podcast Normal Gossip, which I rationed out so that I had something to look forward to. Then I napped. And napped. And napped. I wasn’t getting better. In fact, I was getting worse.

The first studies that asked participants to exercise through their concussion symptoms were controversial. “People were worried you’d do serious permanent harm,” Iaccarino said. In 2009 Canadian researchers recruited 16 children and teenagers between the ages of 10 and 17. All had endured concussions; all had initially followed their doctors’ advice to rest; and all were still suffering from symptoms four or more weeks later. Every day, the researchers had the children do 15 minutes on the treadmill or stationary bike at about 50 percent of their maximum effort, then 10 minutes of drills for their respective sport. If the kids’ symptoms ramped up during a session, they were told to stop. Within five weeks, on average, the children and teens made complete recoveries. Then, in 2016, a JAMA study of more than 2,400 young athletes found that among those who followed a strict resting protocol, 43.5 percent still had symptoms after 28 days. Among those who resumed activity within the first week, sometimes in spite of symptoms, that proportion fell to 24.6 percent. Gradually, other studies added to the evidence that people who engage in activity—even in the hours immediately after their concussion—fare better than those who didn’t. The activity in question doesn’t even have to be physical. A 2022 study published in the journal Pediatrics found that children who spent less than two hours a day on screens in the first week after a concussion had worse concussion symptoms after one month than did those who engaged in “moderate” screen time of two to seven hours a day.