Concussions: Parents Are Critical Participants in Recognition, Treatment, Recovery

7.  Physical and "cognitive" rest:

Treating young athletes after a concussive event is uniquely challenging, because their brains are still developing, and their recovery is usually slower than that with adults. 

Avoiding strenuous activity until the athlete has no post-concussion symptoms at rest is still advised if it makes symptoms worse and such activity has the potential to delay recovery.  While bed rest is not recommended, there is some evidence to suggest that a limited amount of physical activity may actually help in recovery, and, while the effect of physical activity on concussion recovery has not been extensively researched, there is general consensus among concussion experts on broad restrictions on physical activity after concussion, including:  

• the sport or activity that resulted in the concussion
• weight training
• cardiovascular training
• PE classes
• sexual activity
• eisure activities such as bike riding, street hockey, and skateboarding that risk additional head injury or make symptoms worse. [3]

But a growing number of concussion experts now believe that it may actually better for a student-athlete to return to school, at least part-time, after one or two days of rest at home, and that complete cognitive rest (no reading, homework, online activity, video games, text messaging and staying home from school [2,7] for an extended period of time has downsides, and that reduced reading, less homework, working less online, and text messaging less may be all that is required. [14]  

While a recently-published study in the journal Pediatrics [12] found that student-athletes who reduced their cognitive activity the least took from 2 to 5 times longer on average to recover from concussion than those who limited cognitive activity,  researchers also found, that while limiting cognitive activity was associated with a shorter duration of symptoms, complete abstinence from cognitive activity didn't help speed recovery and may be unnecessary. 

Most recently, a group of concussion experts meeting in October 2015 at a conference at the University of Pittsburgh Medical Center are said to have concluded [15]  that strict physical and cognitive rest beyond the first few days after a concussion was not necessary.  

"Exercise is a way of treating this," Dr. Javier Cardenas, a neurologist at the Barrow Concussion and Brain Injury Center in Arizona, told the Pittsburgh Post-Gazette at the time of the conference. "Many times, we see patients who are completely restricted from any physical activity. As one of the major sources of this injury is sports and athletics, for those who are involved in athletics, this is actually a punishment. They become depressed. They become anxious. So allowing them to participate in physical activity - while keeping them out of harms' way, of course - is actually a rehabilitation method."

Another concussion expert who believes that complete cognitive rest may be over-prescribed is Elizabeth M. Pieroth, Pys. D., a clinical neuropsychologist with North Shore Medical Group in Chicago and a consultant to a number of Chicago professional sports teams, including the Bears, and an unpaid consultant to the National Football League.

Like Dr. Cardenas, Dr. Pieroth sees many of the same downsides to keeping concussed athletes out of school for more than a few days after injury, including social isolation, depression, and an unhealthy focus on symptoms instead of recovery.

The American Academy of Pediatrics, [11] mindful of the fact that it is difficult for parents to constantly be monitoring their child and to enforce strict limits on texting, video gaming, computer and TV use and of the relative lack of research in this area, [11] suggests that the most important thing for a parent to take a common sense approach about their child's level of cognitive activity, having the child avoid activities that seem to make their symptoms worse.

If symptoms are severe, academic accommodations, including a temporary leave of absence from school may be necessary if symptoms. [10]  It is reasonable for a child to miss a day or two of school after concussion, and shortening of the athlete's school day, reduction of workloads in school, and/or allowing an athlete more time to complete assignments or take tests, may be necessary. [2,3,7,10, 11]

Taking standardized tests while recovering from a concussion should be discouraged, because lower-than-expected test scores may occur and are likely not representative of true ability.

8.  Graduated, individualized, conservative return-to-play.  All recent position and consensus statements on sport-related concussion [1,2,3,7,10] strongly recommend against - and most of the new state laws prohibit - same day return to play in case of suspected concussion, under any circumstances. 

When returning athletes to play, student-athletes should:

• be off all academic accommodations (or temporary "adjustments," in the new nomenclature suggested by the AAP in its 2013 clinical report on return to learn); [11]
• be symptom-free;
• be at baseline on neurocognitive, balance, and visual tests, and 
• have successfully completed a 5 step, symptom limited exercise program - which will usually take about a week to complete, with each stage taking 24 hours or longer; if symptoms recur with exertion or at rest at any stage, the athlete returns to the previous stage and tries again 24 hours later. 

Parents need to remember that concussion management is not one-size, fits all and needs to follow an individualized course tailored to their child's unique situation, as each athlete will recover at a different rate (especially for athletes with a history of multiple concussions).[11]

However, as a general rule, because a number of studies have shown that younger athletes take longer to fully recover cognitive function than college-aged or professional athletes, a more conservative approach is recommended in deciding when a pediatric and adolescent athlete can return to play, even if they show no symptoms of concussion [1,3], with the Zurich consensus statement stating that it "is appropriate to extend the amount of asymptomatic rest and/or length of the graded exertion in children and adolescents."

Indeed, MomsTEAM expert sports concussion neuropsychologist, Rosemarie Scolaro Moser, Ph.D., recommends in her book, Ahead of the Game: The Parents' Guide to Youth Sport Concussion [8] that children and teens be held at least three weeks before returning to sports. 

9.  Further testing/management. Until about 12 years ago, concussions were "graded" based on severity, with the concussion grade, the number of concussion suffered, and whether the athlete suffered a loss of consciousness or amnesia determining return to play. Over the last decade, however, concussion grading scales and one-size-fits-all, cookie-cutter return to play guidelines have been abandoned in favor of a much more individualized approach.[14]   

The Zurich consensus statement [1] calls for consideration of so-called "modifying factors," the presence of any of which may suggest the need for more sophisticated, multi-disciplinary concussion management strategies,  such as examination by a specialist, more sophisticated testing, and a longer recovery time.  These factors include:

• Lingering symptoms. In most cases, obvious symptoms of concussions clear within a week. [4] The presence of post-concussion signs or symptoms lasting more than 7-10 days, or symptoms that recoccur with exercise, suggest a more serious concussion;
• Prolonged LOC or amnesia.  An athlete who experiences concussive convulsions or prolonged loss of consciousness (LOC) (one minute or more) or amnesia at the time of injury should be treated more conservatively (although a 2013 study [9] suggests that amnesia is not a risk factor for prolonged recovery from concussion);
• Multiple concussion history.  If the athlete has suffered one or more concussive events in the past, especially where the injuries appear to be recurring with progressively less impact force (e.g. a minor blow) or takes longer to recover after each successive concussion, a longer recovery time, or even a recommendation against returning that season or to that sport in the future may be warranted; and
• Other neurological disorders present.  A concussed athlete with learning disorders and/or attention deficit hyperactivity (ADHD) or a history of migraines [10] may require different concussion management that takes these conditions into account.

10.  Trust your instincts. Be as involved in the management of your child's concussion as your instincts tell you to be. Don't be afraid to ask your child how he is feeling, or take him to his pediatrician or a specialist if you suspect something is wrong, or you notice a change in his/her personality (he is solemn or unusually subdued), appetite (eating more or less than usual), sleep patterns, or that he is, for lack of a better word, "off."  Remember: you know your child better than anyone.  Because there is a lot medical science does not know about concussions, a common sense approach makes - in a word - sense.  

As Dr. Robert Cantu observes in his 2012 book, Concussion and Our Kids, [6] while parents shouldn't attempt to diagnose concussions - that's the job for physicians trained to manage head trauma - that "doesn't excuse moms and dads from the important job of studying  children for signs."  He recommends using "every tool in the parental toolbox," including a series of simple tests that can be given at home:

• short-term memory: A common concussion symptom is a deficit in short-term memory, which can be easily tested by a parent posing a series of questions about recent events, or giving a child a list of unrelated words such as objects or colors and then asking the child to repeat the list back immediately and again in three or four minutes. 
• balance: poor balance is common among concussed athletes.  Can your child stand firm with their feet together, in heel-to-toe tandem position, and on one foot, eyes open and then closed; with hands on hips, eyes open and then closed? 
• open-ended questions about how he is feeling: As Dr. Cantu observes, "it's a question that occurs so naturally to a parent that it hardly needs to be recommended."  But, in the case of concussion, answers to questions like "'Are you having trouble with memory? Have you noticed issues with concentration? Is your homework taking longer? Is doing homework causing a headache that it wouldn't normally? When you study for longer periods, does the headache get worse?'" may suggest that there is either no need for further evaluation (because the child "sails through the evaluation without a sign of a deficit") or raise serious concern (a question about yesterday's game, for instance, stumps your child, and they struggle to keep their balance with eyes closed).  Dr. Cantu's view is that "a child should be seen [by a concussion specialist] if he is trying as hard as he can yet struggles to complete cognitive or balance tests." 

"[P]arents should be acutely aware of [concussion] symptoms, potential differences between girls and boys, and alert coaches and healthcare workers to behavioral changes," advises Susan A. Saliba, PhD, PT, ATC, an Assistant Professor at the Curry School of Education; Physical Medicine and Rehabilitation at the University of Virginia, and the co-author of a 2010 study on concussions among high school athletes. [5]   

"Parents have the ability to observe the athlete longer and can perceive changes that may affect the outcome.  Any lethargy, continued headache, or change in behavior or affect can be concussion symptoms, especially if agitation or difficulty in concentrating are present.  Many times the parent cannot identify a specific symptom, but should nevertheless alert someone that the athlete is 'not him or herself.' Early return to play during this time presents the most danger," she says.   

An athlete's school and coaches should maintain regular contact with his or her parents to update them on their progress.

For the most comprehensive, up-to-date concussion information on the Internet, click here. 

Brooke de Lench is Founding Executive Director of MomsTEAM Institute, Founder and Publisher of MomsTeam.com, author of Home Team Advantage: The Critical Role of Mothers in Youth Sports, and Producer and Director of the PBS documentary, The Smartest Team: Making High School Football Safer.

Join MomsTeam on Facebook for tips and youth sports news and follow MomsTeam on Twitter @momsteam. 

Sources:

1. 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.

2. Sport Concussion Assessment Tool 3, Br J Sports Med 2013;47:259.

3. Halstead, M, Walter, K. Clinical Report - Sport-Related Concussion in Children and Adolescents. Pediatrics 2010;126(3):597-615.

4. Meehan W, d'Hemecourt P, Comstock D, High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. Am. J. Sports Med. 2010;38(12): 2405-2409 (accessed December 2, 2010 at http://ajs.sagepub.com/content/38/12/2405.abstract?etoc).

5. Frommer L, Gurka K, Cross K, Ingersoll C, Comstock R.D., Saliba S. Sex Differences in Concussion Symptoms of High School Athletes. J Ath Tr. 2011;46(1):000-000.

6. Cantu,R, Hyman, M. Concussions and Our Kids (Houghton Mifflin Harcourt 2012). 

7. Child-SCAT 3.  Br J Sports Med 2013;47:263. 

8. Moser R. Ahead of the Game: The Parents' Guide to Youth Sports Concussion (Dartmouth College Press 2012), p. 102.

9. Meehan W, Straccioloni A, Elbin R, Collins M. Symptom Severity Predicts Prolonged Recovery after Sport-Related Concussion, but Age and Amnesia Do Not. J Pediatrics 2013;DOI 10.1016/j.jpeds.2013.03.012.

10. Harmon K, 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.

11. Halstead ME, et al. Clinical Report - Returning to Learning Following a Concussion. Pediatrics doi:10.1542/peds.2013-2867 (epub October 27, 2013).

12. 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.

13. Lin A, Salzman G, Bachman S, Burke R, et al. Assessment of Parental Knowledge and Attitudes Toward Pediatric Sports-Related Concussions. Sports Health: Multi-Disciplinary Approach. 2015;7(2):124-129. doi: 10.1177/1941738115571570 (Published online before print February 6, 2015)

14.Broglio SP, Cantu RC, Gioia GA, Guskiewicz KM, Kutcher J, Valovich McLeod TC. National Athletic Trainers' Association Position Statement: Management of Sport Concussion. J Ath Tr. 2014;49:245-265.  

15. Mike Florio. "Concussion conference suggests that rest may not be the best treatmen.t" NBC Sports Pro Football Talk. October 17, 2015 (accessed November 3, 2015 at http://profootballtalk.nbcsports.com/2015/10/17/concussion-conference-su...) 

Most recently updated April 30, 2016