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."
Importance of cognitive rest: debate continues
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" 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 a post-concussion syndrome. Our research and clinical practice has consistently supported the importance of a solid period of comprehensive rest and then transition back to school."
Longer period of rest needed?
Moser also questioned the authors' 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, 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."
1. Halstead ME, et al. Clinical Report - Returning to Learning Following a Concussion. Pediatrics doi:10.1542/peds.2013-2867 (epub October 27, 2013).
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...).
3. Rocky Mountain Youth Sports Medicine Institute, Center for Concussion. REAP Guidelines. Available at: http://www.rockymountainhospitalforchildren.com/sports-medicine/concussi.... (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.
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
Posted October 27, 2013