Return to learn after concussion in children

Cognitive deficit after a head injury

Cognitive functions such as attention, memory, concentration, and reaction time have been shown to be affected soon after concussion, altering school performance and learning.⁸ Animal studies suggest that cognitive and physical activity after concussion redirects highly sought-after glucose away from the brain, thereby slowing its restoration of function.⁹ The neurometabolic cascade that ensues following brain trauma is largely responsible for the subjective symptoms experienced by children.¹⁰ This theory serves as the basis for the general recommendation to limit academic activity shortly after a concussion in order to allow proper recovery and reintegration into school and activities.¹⁰

Prescribing cognitive rest

The extent of cognitive rest needed is currently unclear. Which children should implement a cognitive rest program? For how long? How strict should the cognitive rest be?

Recommendations for cognitive rest include postponement of homework or staggering of tests⁸; rest periods during school⁸; avoidance of reading, video games, texting, and computer screen time; and for some children in whom it triggers symptoms, no television viewing or school.¹¹ The guiding principle throughout recovery is to try and maintain cognitive activity below the level that triggers symptoms.¹¹

Baker et al examined concussion-related problems in the school setting among student athletes aged 13 to 19 years from Buffalo, NY, and reported that 35 of 91 (38%) students had presenting symptoms, including difficulties paying attention and following directions in class, feeling confused, experiencing light-headedness, and being fatigued.¹² These findings were mostly associated with students who had initial high SCAT scores (severity) and who had greater numbers of symptoms at the initial visit.¹² Scores from the SCAT at the initial clinic visit of those students who reported difficulties with returning to school were higher than scores for those who reported no difficulties after returning to school (23.3 vs 13.5, respectively; maximum score was 132), with the average number of symptoms being 9.5 for those who reported difficulties with returning to school versus 6.2 for those with no difficulties returning to school (maximum number of symptoms was 22).¹² School concerns were not associated with sex, age, or history of previous concussion, which suggests all students should receive return-to-learn instructions, particularly those with high initial scores and total number of symptoms.¹² The initial visit might be an inaccurate representation of the severity of the concussion; children presenting with symptoms at 10 days after concussion are likely to have difficulties in school and might benefit from cognitive rest.¹²

Similarly, Brown et al prospectively followed a cohort of patients aged 8 to 23 years (mean age 15 years) who presented to a sports concussion clinic within 3 weeks of injury.¹³ Symptoms such as headache, drowsiness, irritability, and difficulty concentrating were measured using the Post-Concussion Symptom Scale,¹⁴ and patients were deemed asymptomatic once their symptom score was zero.¹³ Brown et al concluded that those with more severe symptoms at the first clinical visit and those with the highest level of cognitive activity had the longest time to symptom resolution.¹³

How strict should cognitive rest be?

In a 2015 study by Thomas et al,¹⁵ patients from a children’s hospital ED who presented with mild concussion were randomized to either a strict cognitive rest approach or to usual care (ie, 1 to 2 days of rest followed by a stepwise return to usual activity). Differences in physical activity levels between the 2 groups were not considerable owing to lack of compliance with the strict regimen; however, those meant to adhere to strict cognitive rest had less mental activity.¹⁵ This group reported more postconcussive symptoms from a 19-symptom Post-Concussion Symptom Scale,¹⁴ which assessed symptoms in 4 domains (ie, physical, cognitive, emotional, and sleep).¹⁵ Those who followed a strict cognitive rest approach had longer time to symptom resolution compared with those who returned to usual activity gradually after 1 to 2 days of cognitive rest (3 days longer for 50% of those in the strict cognitive rest group).¹⁵ Limited school attendance can cause anxiety, and symptoms of depression and anxiety often mimic concussion symptoms,¹⁶ adding to the challenge of determining symptomatology.¹⁶

Buckley et al reported a comparison of postconcussion recovery times between patients who were assigned an average of 40 hours of strict cognitive rest (being withheld from all activity) and those who had no postinjury accommodations.¹⁰ Participants were included if they had endured a typical concussion (one which had resolved within 1 month), and those with more extensive comorbidity were excluded.¹⁰ After all other factors were controlled for, including initial concussion severity, children who were in the group not assigned to any postinjury accommodations became asymptomatic sooner than those who were assigned strict cognitive rest (mean [SD] of 3.9 [1.9] days vs 5.2 [2.9] days).¹⁰

Majerske and colleagues showed that after varying degrees of concussion, those who participated in moderate levels of activity as opposed to no activity or high levels of activity demonstrated the best outcomes in terms of neurocognitive and symptomatic recovery up to 33 days after concussion.¹⁷ At a sports concussion clinic, the highest level of cognitive activity (top quartile) was associated with the most prolonged course of recovery.¹³ Children with less cognitive activity, in the bottom 3 quartiles, had similar times to recovery, suggesting that complete restriction of activity is likely unnecessary and possibly unfavourable,¹³ as it is associated with anxiety, classroom absenteeism, and a lack of engagement in healthy activities.¹⁶

The most recent International Conference on Concussion in Sport⁵ recommends 24 to 48 hours of both cognitive and physical rest following concussion before beginning the return-to-learn approach.⁵ However, Taubman et al published evidence to support implementation of a return-to-learn approach from the onset of concussion.¹⁸ Children and adolescents aged 11 to 19 who experienced concussion were told to avoid school, homework, and video games but were otherwise allowed to continue normally as long as they remained asymptomatic. In this study, delayed implementation of rest for 1 to 7 days was associated with a 4.6-day prolongation of symptoms on average (mean [SD] of 10.29 [5.83] days for those with immediate cognitive and physical rest vs 14.42 [6.15] days for those with delayed cognitive and physical rest; P = .005).¹⁸ By following the prescribed gradual return-to-learn approach from concussion onset, children avoided symptom-provoking activities until they could be accomplished symptom free.¹⁸