Emergency department visits due to sports-related head injuries in children have increased 60% over the past 10 years. In high school athletes, concussions account for more than 10% of all sports-related injuries. A generation ago, physicians, parents, and coaches under-appreciated symptoms and the physical and cognitive disabilities caused by concussions. Then, patients might have been told to shake it off or take a short rest before being sent back onto the field, rink, or court. Missing school because of a headache after a head bang was not encouraged, so probably a lot of concussed student-athletes bombed a few weeks of schoolwork, stumbling around their school’s hallways in a fog until they finally recovered.
There has been a revolution in understanding the physical mechanisms causing concussions, as well as the physiological and chemical contributors to symptoms which can be fairly mild to profoundly severe. Strides have been made in evaluating severity and monitoring recovery through more focused physical exam techniques and neuro-cognitive computerized testing (like ImPACT testing). The concept of “brain rest” for a few days to aid in the immediate recovery of a concussion is not new and reflects that fact that most patients with significant concussion symptoms really can’t do much of anything anyway due to symptoms like headache, nausea, dizziness, fogginess, sensitivity to light and sound, and fatigue. For pediatricians, brain rest usually means forcing the complete shut down of physical and mental activities.
Shutting a child or teenager down — no reading, no screen time, no homework, no TV (literally, no nothing except eating, sleeping, and using the bathroom) — is easier said than done. Telling a teenager to do nothing — especially a student athlete who is used to being very active mentally and physically — may sound good to them initially. And it is good — for about 10 minutes! After that, compliance with the prescription of “no activity at all” is probably poor, particularly if that recommendation comes with the nebulous timeline to stop “when you are feeling better” (which may be a few days to a few weeks or more).
Earlier this month, a new study was published in Pediatrics questioning the wisdom of prescribing prolonged brain rest for concussed teenagers. Steven Reinberg says 1-2 days of brain rest followed by the resumption of moderate physical and mental activity might be just the right advice:
The researchers compared five days of strict rest to the traditionally recommended day or two of rest, followed by a gradual return to normal activities as symptoms disappear.
The Medical College of Wisconsin researchers found no significant difference in balance or mental functioning between teens who rested five days and those who rested one to two days.
What’s more, those children assigned to five days of strict rest reported more symptoms that lasted longer.
Trying to find that “Goldilocks Zone” of physical and mental rest (not too much, not too little, just enough) is the challenge physicians and other providers who manage concussions face in getting these students back to school learning and, later on, back on the field playing.
With our goal on preventing, at all costs, a second concussion while the patient is recovering from the initial head injury, it would be prudent to follow these steps when managing a concussion:
- Loss of consciousness, altered mental status (confusion, very slow processing abilities), and severe nausea and vomiting are symptoms that require an emergency department evaluation and, most likely, brain imaging. (Most concussions do not require emergency department visits or brain imaging like CT or MRI scans.)
- Evaluation by a provider trained in managing concussions (like most pediatricians at Pediatric Alliance) should occur within 1-3 days of the injury so the mechanism of injury and the severity of symptoms can be assessed through physical examination and neuro-cognitive testing when appropriate, and a plan of action formulated.
- Physical and mental rest for those few days before that appointment, keeping life quiet and restful and focusing on hydration, nutrition (real food), and rest.
- If symptoms of concussion and neuro-cognitive testing (especially scores for processing) allow, a gradual return to school (with appropriate, carefully written requests for accommodations regarding in-school and homework assignments) should be encouraged. Returning to school will also allow a low-moderate return to physical activity as long as active recess, gym class, and participation in sports are prohibited in order to prevent a second concussion.
- Reassessments by the same provider with serial exams and computerized neuro-cognitive testing should be scheduled until concussion symptoms resolve and physical exam findings and neuro-cognitive testing results return to previously-documented baseline levels.
- Once baseline criteria are achieved, school accommodations can be removed and a “return-to-play” plan can be established and instituted.
- Only when an athlete can follow a return-to-play protocol without triggering new concussion symptoms is that patient formally cleared to play, and the concussion deemed “resolved.”
More PediaBlog coverage of concussions here.