The US Centers for Disease Control and Prevention estimates that there were approximately 1,400 emergency department visits for traumatic brain injury per 100,000 people in 2010.1 Symptoms of concussion can be varied, but may include headache, nausea, difficulty concentrating, “fogginess,” irritability, dizziness, poor sleep, and mood disturbance. The majority of research has been done on adolescents older than age 12 years and those that sustained concussions from sport-related injuries. Therefore, in young children and in those with nonsports injuries, the evidence is more limited.
Before Returning to School
Cognitive and physical rest is the primary treatment for concussion. Step-wise return-to-play guidelines have already been established and are widely used among pediatric primary care providers and sports medicine physicians2 (Table 1). In contrast, the approach to return-to-school may vary between patients and must be approached on an individualized basis. Additionally, just because a patient is asymptomatic does not mean that they have full neurocognitive ability.3 Most students will lack outward signs of concussion by 1 week after their injury (no headaches or nausea), but may not have returned to neurocognitive baseline. In other words, they may appear asymptomatic, but their postinjury cognition may be different compared to their preinjury cognition. Students may need additional time to get back to their baseline neurocognitive function, as measured by neuropsychologic testing.3 Patients may look and act normally after a concussion, leading school administrators and teachers to question a students' dismissal from school or assignments. Therefore, the pediatrician must be ready to advocate for the patient's gradual return to a full academic workload. Some studies have demonstrated that full recovery (with no outward symptoms of concussion and cognition back to baseline) usually occurs within 3 weeks after the injury, although adjustments may need to be made during this time to facilitate a gradual return-to-learn.4
Any activities that worsen concussion symptoms, including reading, homework, screen time, texting, or video games should be avoided. Visits with friends or trips may need to be limited as well. Light mental activities that do not exacerbate symptoms may be done, such as interaction with family. Avoidance of loud music and activities that require sustained focus, such as standardized tests, may also be necessary. Some studies suggest that adolescents who engage in high levels of cognitive/physical activity have longer recovery times compared to those that engage in moderate to low levels of activity.5
One study suggests that a good estimation of when a student can return to school is if they can tolerate 30 to 45 minutes of concentration.6 Return can be graduated, starting with partial participation, then eventually back to full school participation. There is no recommended time that a patient should avoid school after a concussion. There is even some evidence that patients that are prescribed a set amount of rest, such as 5 days, may experience more daily postconcussive symptoms compared to those that took a gradual approach (1–2 days of rest followed by a gradual return to full cognitive activities).7 Additionally, prolonged absence from school may be harmful to the patient's academic success, and may pull them away from social supports at school. Therefore, the return to school must be treated on an individual basis.
School Accommodations for Students
Once a student returns to school, there are many ways that the school day can be altered to facilitate a gradual return to full academic participation. Accommodations can be made regarding the type and amount of schoolwork as well as the length of time in each class or the number of classes in which a student participates. Table 2 lists accommodations that can be proposed for a patient recovering from a concussion.
Accommodations for Concussion Recovery
Primary care pediatricians can help coordinate this effort by diagnosing the concussion and ensuring there are no more serious injuries present, and also prescribing rest as appropriate. A sample note is available from the American Academy of Pediatrics8 that lists the possible temporary accommodations that can be made for a student. The pediatrician should also have the family sign a waiver allowing the physician to discuss the diagnosis and treatment plan with the school administration. The school administration may include a school nurse, a teacher or teachers, the sports coach or trainer, a school psychologist, or other school leadership. If accommodations are needed on a prolonged basis, greater than 3 weeks, a formal 504 plan may be warranted.6
Monitoring of Symptoms
Patients should be assessed at the time of injury and periodically during recovery if there are severe symptoms requiring prolonged school absence or if any symptoms persist longer than 2 weeks. There are standardized tools that exist that can help clinicians score symptoms, such as the Sports Concussion Assessment Tool.9 These tools may help to quantify symptoms and help the clinician understand how patients' scores change over time. They are also easily administered in a pediatrician's office.
Neurocognitive testing may be a helpful tool to assess a student's symptoms after concussion, but it has not been studied enough to determine when and how a student is ready to return to a full academic workload.7 There are written neurocognitive tests and there are computerized tests. Advantages of the computerized tests include that they can be completed quickly and yield results immediately upon completion. Additionally, these tests are most useful if done before the patient has an injury, so that after the injury they are able to compare the postinjury score to the individual baseline. This is important because many patients have sleep disturbance, mood disorders, attention-deficit/hyperactivity disorder, or learning difficulties at baseline, which may alter neuropsychologic testing. Some schools conduct neuropsychologic testing on their players before the sports season begins to get baseline data before any injuries occur. Most often, follow-up neuropsychologic testing is done in consultation with a concussion specialist or sports medicine specialist.
When to Get Help from a Specialist
The majority of concussions can be easily managed by the primary care pediatrician. There are a few situations in which a pediatrician may seek consultation from a concussion or sports medicine specialist. These include patients with (1) prolonged symptoms, lasting more than 2 weeks; (2) severe symptoms that do not respond to typical treatment; (3) difficulty with returning to school, specifically those requesting absences lasting more than 5 days; and (4) a history of multiple concussions.
Recovery from concussion is a dynamic process, and is different between patients and even different between concussions in the same patient. The majority of concussions resolve with rest and gradual return to physical and cognitive activity. Although patients may be asymptomatic within hours or days, they may not return to neurocognitive baseline until later. Any activities, physical or cognitive, that exacerbate concussion symptoms must be ceased temporarily. With a few tips from this article (Table 3), the primary care pediatrician can help coordinate with the school administrative team to plan for a smooth recovery and gradual return to a full school workload.
- Centers for Disease Control and Prevention. Rates of TBI-related emergency department visits by sex — United States, 2001–2010. http://www.cdc.gov/traumaticbraininjury/data/rates_ed_bysex.html. Accessed February 11, 2016.
- Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47:15–26. doi:10.1136/bjsports-2012-091941 [CrossRef]
- Iverson GL, Brooks BL, Collins MW, Lovell MR. Tracking neuropsychological recovery following concussion in sport. Brain Inj. 2006;20:245–252. doi:10.1080/02699050500487910 [CrossRef]
- 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. doi:10.1227/01.NEU.0000200441.92742.46 [CrossRef]
- Brown NJ, Mannix RC, O'Brien MJ, et al. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014;133:e299–e304. doi:10.1542/peds.2013-2125 [CrossRef]
- Halstead ME, McAvoy K, Devore CD, et al. Returning to learning following a concussion. Pediatrics. 2013;132:948–957. doi:10.1542/peds.2013-2867 [CrossRef]
- Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135:213–223. doi:10.1542/peds.2014-0966 [CrossRef]
- American Academy of Pediatrics. Council on Sports Medicine & Fitness. Return to learning after concussion sample note. https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Council-on-sports-medicine-and-fitness/Pages/Sample-Return-to-Learning-Note-for-Physicians.aspx. Accessed February 11, 2016.
- Sports Concussion Assessment Tool – 3rd Edition. http://bjsm.bmj.com/content/47/5/259.full.pdf. Accessed February 11, 2016.
|Step 1. No activity
|Step 2. Light aerobic activity
|Step 3. Sport-specific activity
|Step 4. Noncontact training drills
|Step 5. Full-contact practice
Accommodations for Concussion Recovery
Shortened school day
Fewer activities that require exertion (physical education, playing wind instruments)
Allowance for breaks during the school day, such as rest in the nurse's office
Allowance for a student to rest during class if symptoms worsen
Reduction in workload or shorter assignments
More time to complete assignments
Individual tutoring or a peer helper
Preferential classroom seating
Fewer or postponement of tests
Extra time to complete assignments or tests
Quiet room to complete assignments or tests
Avoidance of noisy areas (cafeterias, assembly halls, sporting events, music class, shop class)
There is no prescribed amount of time that is recommended for children to be absent from school after a concussion
The majority of students will be asymptomatic by 1 week after injury, but may take as long as 3 weeks or more to return to neurocognitive baseline
There are many school accommodations that can be made for a student, specifically regarding the number/type of classes, the length of the class or school day, and postponement of important standardized tests
Return-to-learn must be on an individualized basis, balancing the gradual return to full neurocognitive ability with the possibilities of social isolation and poor academic performance that may accompany prolonged school absence