Delicate balance
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
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"[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. Our research[8] and clinical practice has consistently supported the importance of a solid period of comprehensive rest and then transition back to school."
New support for cognitive rest and academic accommodations
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.
