Helping a student-athlete make a successful return to learning after a concussion is just as important as ensuring their safe return to sports, and requires a team approach involving parents, health care professionals, and schools, says the American Academy of Pediatrics. [1]
"Students appear physically normal after a concussion, so it may be difficult for teachers and administrators to understand the extent of the child's injuries and recognize the potential need for academic adjustments [1]," said lead author, Mark Halstead, the author of the AAP's 2010 guidelines [2] for pediatric concussions.[2]
"We know that children who've had a concussion may have trouble learning new material and remembering what they've learned, and returning to academics may worsen concussion symptoms," writes Halstead.
The report said it it was "unfortunate that [so] little attention has been given to academics and learning and how a concussion may affect the young student learner."
"Every concussion is unique and symptoms will vary from student to student, so managing a student's return to the classroom will require an individualized approach," said Halstead. "The goal is to minimize disruptions to the student's life and return the student to school as soon as possible, and as symptoms improve, to increase the student's social, mental and physical activities."
Research, the report says, has shown that a school-aged student usually recovers from a concussion within three weeks. If symptoms [3] are severe, some students may need to stay home from school after a concussion. If symptoms or mild or tolerable, the parent may consider returning him or her to school, perhaps with some adjustments, says the AAP.
Students with severe or prolonged symptoms lasting more than 3 weeks (the point at which some experts classify a concussed student as having post-concussion syndrome [4]) may require more formalized academic accommodations, the group says.
"Overall, the authors should be commended for providing this educational and informative piece discussing concussion and the effects on students," said sports concussion neuropsychologist Rosemarie Scolaro Moser, PhD [5], Director of the Sports Concussion Center of New Jersey and a MomsTEAM concussion expert. "Their assertions that concussion management is a team approach, that each concussion is unique, that students need academic accommodations are important public messages. It is a great first step in educating pediatricians about this growing public health concern and their roles in concussion team management," Moser said.
To that end, the AAP report, not surprisingly, contains a host of specific recommendations for pediatricians, including that they:
The report provides helpful information on the potential implications in school for a student experiencing particular concussion symptoms and the kind of adjustments that may be required as a result:
Sign/Symptom | Potential Implications in School |
Potential Adjustments |
Headache |
|
|
Dizziness [12]/lightheadness |
|
|
Visual symptoms: light sensitivity, double vision, blurry vision |
|
|
Noise sensitivity |
Troubles with various aspects of the school environment
|
|
Difficulty concentrating or remembering |
Challenges learning new tasks and comprehending new material:
|
|
Sleep disturbances |
|
|
The AAP recommends that pediatricians work collaboratively with a mulit-disciplinary team consisting of the concussed student and their family, school and other medical personnel and individuals at the child's school responsible for both the student's academic schedule and physical activity, to ease the transition back to the school environment and facilitate reocovery.
Team |
Members | Role/Responsibilities |
Family team |
Students, parents, guardians, grandparents, peers, teammates, and family friends |
|
Medical team |
Emergency department [16], primary care provider [16], concussion specialist (primary care sports medicine physicians, neurologists, neurosurgeons, as examples), clinical psychologist, neuropsychologist [17], team and/or school physician |
|
School academic team |
Teacher, school counselor, school psychologist, [19] social worker, school nurse, school administrator, school physician |
|
School physical activity team |
School nurse, athletic trainer, [20] coach, physical education teacher, playground supervisor, school physician |
|
While laws may vary by state, writes Halstead and his colleagues, "it remains essential that all [schools] recognize the importance of team management for a student after concussion and ensure that all students recovering from concussion have assigned staff who will be responsible for smooth reentry to school."
"The challenge of the multidisciplinary team is to balance the need for the student to be at school with the appropriate adjustments for the cognitive demands at school that have the potential for increasing symptoms. To reach the right balance at home and school, the multidisciplinary teams should be well versed in their roles and responsibilities in concussion management and keep communication open among all parties regarding decisions to progress, regress, or hold steady during the RTL process," says the report.
"Education regarding concussion generally, and the role of cognitive and physical rest and return to school, specifically, is essential for the teams of individuals helping a student with concussion during assessment, management, and recovery. This education should extend to both school personnel (eg. administrators, athletic directors, teachers, guidance counselors, school psychologists, coaches, school physicians, school nurses, ATs) and individuals likely not employed by the school (eg. primary physicians, sports/team physicians, emegency department physicians, parents, and other caregivers)," says Halstead.
The challenge is that, even in states with legislation requiring concussion education and management, "nonathletic personnel in schools are often left out of concussion education efforts." Taking a comprehensive team approach, suggests the AAP, "may help reduce mistakes in management, which could potentially risk reinjury during the healing phase, lengthen recovery, or result in untoward long-term outcomes."While recognizing the importance of cognitive rest following a concussion, Moser felt that the AAP could have more "strongly emphasized the essential message that all parents, athletes, and professionals should know, which is to rest the brain immediately and comprehensively if you suspect a concussion, and if you want to heal quickly and prevent prolonged symptoms."
The authors, she noted, were not clear as they could have been on the cognitive rest issue, making what seemed to be conflicting statements about its benefits. On the one hand, she says, they pointed to an absence of "research documenting the benefits or harm [of avoiding potential cognitive stressors, such as texting, video games, TV exposure, and schoolwork] in either the prolongation of symptoms or the ultimate outcome for the student following concussion," but, on the hand, said that there was "increasing evidence" [21][10] that using a concussed brain to learn - the precise opposite of cognitive rest - "may worsen concussion symptoms and perhaps even prolong recovery." "So which is it?" Moser asked.
Moser also expressed concern that the AAP was advising parents to return their concussed child to school as soon as possible. "Don't be afraid to keep your child home for a week to get rid of the headache," she said, emphasizing that cognitive rest after concussion does not require a "period of sensory deprivation, which can be very stressful for the student."
In her clinical practice as Director of the Sports Concussion Center of New Jersey, Moser said she had found that "a one-week comprehensive rest period, with a specific list of activities to avoid, as well as a list of acceptable activities, is the best treatment that helps students return quickly back to school."
In Moser's view, "too many students return to school after a day or two, and try to 'tolerate' or fight the symptoms while in school, often being sent home repeatedly, only to prolong their recovery and end up on home-bound instruction and with post-concussion syndrome [4]. Our research[8] and clinical practice has consistently supported the importance of a solid period of comprehensive rest and then transition back to school."
Dr. Moser's recommendation for cognitive rest and a gradual return to the classroom with accommodations finds important support, at least in part, in a 2014 study finding that teens who continue to engage in full cognitive activity after sport-related concussion take longer to recover than those who limit such activity,[10]but that only those concussed athletes who engaged in the most cognitive activity experienced a significantly longer recovery as measured by the duration of concussion-related symptoms, with those who engaged in less cognitive activity - ranging from complete cognitive rest to significant, but reduced cognitive activity - all recovered at about the same pace.
The findings of that study were seen by its authors, including William P. Meehan, III, MD, Director of the Sports Concussion Clinic at Boston Children's Hospital and a MomsTEAM expert, as adding "empirical support to the practice of putting academic accommodations in place for student-athletes suffering from sport-related concussions ... [to] allow for relative cognitive rest in [a] school setting. ... Given our finding, it is likely that academic accommodations can speed the recovery process," they write.
Commenting further on the study, Dr. Meehan noted that "While vigorous cognitive exertion appears detrimental to recovery, more moderate levels of cognitive exertion do not seem to prolong recovery substantially," findings similar to those in a 2008 study, [11] which found that those who engaged in moderate levels of activity had better outcomes than those engaging in the highest and lowest levels of activity.
"This seems to suggest that while limiting cognitive activity is associated with a shorter duration of symptoms, complete abstinence from cognitive activity may be unnecessary," write Dr. Meehan and colleagues in the study.
Because the effect of cognitive rest may vary over time, such that cognitive activity has more of an effect on recovery during the earlier phases, current concussion guidelines,[2,5,12-14] as well as the expert opinion of many clinicians involved in the assessment and management of sport-related concussion, including Dr. Meehan and Dr. Moser, recommend a period of near complete cognitive rest in the first three to five days after injury, followed by a gradual return to cognitive activity, so long as such increased activity does not trigger a return of symptoms.
Moser also questioned the authors' of the AAP clinical report's admittedly arbitrary recommendation that parent consider returning a concussed child back to learning when they are able to "tolerate symptoms comfortably for up to 30 to 45 minutes," as she was unsure what the phrase 'tolerate comfortably' meant.
"If a student, during the first week or more [after concussion], has headaches after being on a computer or reading for 30-40 minutes, then I am not sure how they can sustain a day of school, even with rest breaks between classes. I recommend that parents and students work with a concussion specialist who can tailor a plan for them and decide if the student really completed a long enough comprehensive rest period."
In the same vein, Moser questioned the AAP report's repeated assertion, based on research published in 2006,[6] that almost all pediatric athletes recover from concussion within three weeks, when more recent research using advanced neuroimaging and neuroradiologic techniques, as well as other research, has furnished "increasing evidence to suggest that the youth brain takes much longer to return to normal, likely months."
"Although the authors stress that each concussion is unique and there is no 'cookie-cutter' approach in management," Moser said she was "concerned that parents and health care providers will hinge their expectations [about recovery] on this 'three weeks' idea."
2. Halstead, ME, Walter, K. "Clinical Report - Sport-Related Concussion in Children and Adolescents" Pediatrics. 2010;126(3):597-615 (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;126/3/5... [22]).
3. Rocky Mountain Youth Sports Medicine Institute, Center for Concussion. REAP Guidelines. Available at: http://www.rockymountainhospitalforchildren.com/sports-medicine/concussi... [23]. (accessed June 18, 2013)
4. Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric providers' self-reported knowledge, practices, and attitudes about concussion. Pediatrics. 2012;130(6):1120-1125.
5. McCrory P, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258.
6. SCAT3. Br J Sports Med 2013;47:259 [24].
7. Child SCAT3. Br J Sports Med 2013;47:263.
8. Moser RS, Glatts C, Schatz P. Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sport-Related Concussion. J Pediatrics 2012;161(5):922-926 (after one week of strict cognitive and physical rest, concussed high school athletes scored significantly better on neurocognitive tests and reported statistically significant decreases in the number and severity of post-concussion symptoms)
9. Collins M, Lovell MR, Iverson GL, Ide T, Maroon J. Examining concussion rates and return to play in high school football players wearing newer helmet technology: a three-year prospective cohort study. Neurosurgery. 2006;58(2):275-286, discussion 275-286
10. Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Pediatrics 2014;133(2):1-6.
11. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sport: postconcussive activity levels, symptoms, and neurcognitive performance. J Athl Tr. 2008;43(3):265-274.
12. Giza C, Kutcher J, Ashwal S, et. al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;80(24):2250-2257 DOI:10.1212/WNL.ob013e31828d57dd.
13. Herring SA, Cantu RC, Guskiewicz KM, et al. American College of Sports Medicine Concussion (mild traumatic brain injury) and the team physician: a consensus statement-2011 update. Med Sci Sports Exerc. 2011;43(12):2412-2422.
14.Harmon KG, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47:15-26.
Links:
[1] https://mail.momsteam.com/node/3319
[2] https://mail.momsteam.com/node/3141
[3] https://mail.momsteam.com/node/149
[4] https://mail.momsteam.com/node/3310
[5] https://mail.momsteam.com/node/3468
[6] https://mail.momsteam.com/node/6270
[7] https://mail.momsteam.com/node/6289
[8] https://mail.momsteam.com/node/1335
[9] https://mail.momsteam.com/node/6026
[10] https://mail.momsteam.com/node/2706
[11] https://mail.momsteam.com/node/4176
[12] https://mail.momsteam.com/node/4029
[13] https://mail.momsteam.com/node/4381
[14] https://mail.momsteam.com/node/4139
[15] https://mail.momsteam.com/node/4368
[16] https://mail.momsteam.com/node/5590
[17] https://mail.momsteam.com/node/3549
[18] https://mail.momsteam.com/node/3015
[19] https://mail.momsteam.com/node/6010
[20] https://mail.momsteam.com/node/114
[21] https://mail.momsteam.com/node/7003
[22] http://aappolicy.aappublications.org/cgi/content/full/pediatrics;126/3/597
[23] http://www.rockymountainhospitalforchildren.com/sports-medicine/concussion-management/reap-guidelines.htm
[24] http://bjsm.bmj.com/content/47/5/259.full.pdf
[25] https://mail.momsteam.com/health-safety/neuropsychologist-should-help-plan-academic-accommodations-after-concussion
[26] https://mail.momsteam.com/post-concussion/more-post-concussion-help-students-in-classroom-needed
[27] https://mail.momsteam.com/academic/post-concussion-strategies-for-the-classroom
[28] https://mail.momsteam.com/14-18/concussions-in-youth-sports-team-approach-including-physician-neuropsychologist-and-athletic-trainer-needed
[29] https://mail.momsteam.com/health-safety/parents-critical-participants-in-recognition-treatment-recovery-concussion
[30] https://mail.momsteam.com/health-safety/role-school-psychologist-students-with-sports-related-concussion
[31] https://mail.momsteam.com/cognitive-rest/full-cognitive-activity-after-concussion-delays-recovery-study-finds
[32] https://mail.momsteam.com/5-7/study-confirms-adverse-effect-concussion-academic-learning-performance-children-teens