Concussions and the treatment after one is sustained have been at the forefront of media coverage in recent years. What once was viewed by some as brag-worthy or a badge of honor now is being taken seriously for its potential immediate and long-term effects.
While progress has been made in how the seriousness of a concussion is perceived, it's still relatively unknown when it's acceptable for individuals, including children, to return to normal cognitive and physical activity after suffering one.
According to a study by the Concussion Clinic at Children's Hospitals and Clinics of Minnesota, a child who sustains a concussion during the school year takes significantly more time to recover than one who suffers a similar injury during the summer.
"We were surprised at the magnitude of the differences," Robert Doss, PsyD, co-director of the Pediatric Concussion Program and one of the study's researchers, said. "We weren't surprised that it was in that direction; just simply that the magnitude was what it was."
Researchers took patients seen in the Concussion Clinic at Children's from 2011-12 — 43 children who suffered concussions during the school year and 44 injured in the summer — and monitored their progress. For the children who sustained a concussion in the summer, the average number of days to recover was 35. Recovery time more than doubled (72 days) when the injury was sustained during the school year.
Another study, "Returning to Learning Following a Concussion," published in October in Pediatrics, the official journal of the American Academy of Pediatrics (AAP), explains the difficulties children experience in a school setting after suffering a concussion. Post-concussive symptoms often can linger or increase in severity without proper adjustments to a child's environment or academic routine. Research suggests that academic demands and school environment may be a barrier to recovery.
Because each concussion and child is different, the AAP study recommends creating a multidisciplinary team to facilitate a student's recovery and help him or her return to normal activities. Those four teams are:
- Family (student, parents, guardians, grandparents, peers, teammates and family friends)
- Medical (emergency department, primary care provider, concussion specialist, clinical psychologist, neuropsychologist, team and/or school physician)
- School academic (teacher, school counselor, school psychologist, social worker, school nurse, school administrator, school physician)
- School physical activity (school nurse, athletic trainer, coach, physical education teacher, playground supervisor, school physician).
"It's important to understand the individual child," Doss said. "It seems like our practitioners are noticing more responsiveness by the schools to put forth accommodations for these kids. Some schools are more accommodating than others. Some seem to have a grasp of concussions.
"Overall, I think our perception is that schools are more receptive and thinking about it more actively. They're instituting programs on their own, so they're prepared for what comes next."
Subjects were evaluated and treated in the Concussion Clinic after presenting with symptoms consistent with mild head trauma.
Researchers identified two groups based upon whether they recovered from their concussions during the school year or summer months and were ages 7 and older. The school year was defined as September through May. The school group was matched to the summer group by age and gender.
The average age of the children in the study at the time of injury was 14 years old.
Date of recovery was defined as the final visit date in the Concussion Clinic.
Doss also cautions parents and kids that they aren't out of the woods once recovery is complete.
"It seems pretty clear in some of the guidelines that prior history of a concussion puts you at a higher risk for subsequent concussions," he said.
However, according to the Children's study, there's little empirical support for the amount or duration of cognitive and physical rest after a concussion and the time frame for children to safely return to normal daily activities without experiencing ongoing cognitive or physical deficits.
According to the "Returning to Learning" study, cognitive rest refers to avoiding potential cognitive stressors, such as texting, video games, TV exposure and schoolwork. However, to date, there is no research documenting the benefits or harm of these methods in either the prolongation of symptoms or the ultimate outcome for the student following a concussion.
"Should the kids not be on Xbox versus playing a little bit of Xbox?" Doss said. What may be best during recovery depends on the case. "How much schoolwork is appropriate?"
Doss said the perceptions families and academic institutions have about concussions are evolving.
"Schools across the U.S. did not seem to be prepared. You bump up against the usual: The kids look fine. They're not limping. They have an injury that's not visible," he said. "The general population is dealing with this heightened awareness of concussions."
Variables collected for analysis included school grade, prior concussion history, loss of consciousness with presenting injury, first clinic visit ImPACT computerized cognitive testing raw scores — verbal memory composite, visual memory composite, visual motor speed composite, reaction time — ImPACT post-concussive symptom scores, and history of depression and anxiety, migraine, other neurological problems, learning disability or ADHD.
The study was conducted by Robert Doss, PsyD, Neuroscience Center of Children's Hospitals and Clinics of Minnesota, and Minnesota Epilepsy Group, P.A.; Kara Seaton, MD, Emergency Department of Children's Hospitals and Clinics of Minnesota; and Mary Dentz, RN, CNP; Joseph Petronio, MD; Julie Mills, RN, CNP; Jane Allen, RN, CNP; and Meysam Kebriaei, MD, of the Neuroscience Center of Children's Hospitals and Clinics of Minnesota.