School learning and performance is arguably the critical centerpiece of child and adolescent development, and there can be significant temporary upset in cognitive processing after a mild traumatic brain injury, also called a concussion. This injury results in a cascade of neurochemical abnormalities, and, in the wake of this dysfunction, both physical and cognitive activities become sources of additional neurometabolic demand on the brain and may cause symptoms to reemerge or worsen. This article provides a foundation for postinjury management of cognitive activity, particularly in the school setting, including design and implementation of schoolwide concussion education and management programs.
Learning is the centerpiece of child and adolescent development. Children’s organ of learning is their brain; any adverse event that impairs the brain’s functioning, temporarily or permanently, poses a significant threat to learning. Traumatic brain injury (TBI) of any severity is an adverse event that can threaten the developing child’s future ability to learn. Although more severe forms of TBI may be readily recognized as a threat, greater attention is being paid now to both short- and long-term effects of TBI at the milder end of the spectrum. Recent advances in concussion research have provided clinicians with numerous means to recognize and assess mild TBI, commonly known as concussion. It is now widely recognized that neurometabolic dysfunction is a key aspect of a concussive injury, involving a cascade of neurochemical abnormalities following a force to the brain. In the wake of this cascade, both physical and cognitive activity become sources of additional neurometabolic demand and stress on the brain. A basic assumption of recovery is that symptom exacerbation after physical or cognitive activity is a signal that the brain’s dysfunctional neurometabolism is being pushed beyond its tolerable limits. Management of neurometabolic demands on the brain, therefore, is central to not exceeding the physiologic threshold, thus worsening symptoms and possibly prolonging recovery. Historically, physical rest has been the primary focus of attention in treatment of mild TBI. The focus on physical rest alone, however, does not address mental or cognitive exertion, which is essential for the student’s functioning in school. The need for cognitive rest is advocated in the last 2 international consensus statements on concussion in sport and requires explicit attention in the school setting. This article provides a foundation for designing a concussion education and management program in the school setting.
Concussion basics
Mild TBI is defined as a direct or indirect force to the head that results in immediate short-lived neurologic impairment (eg, amnesia, loss of consciousness, confusion) that resolves spontaneously, typically followed by physical, cognitive, emotional symptoms and sleep disturbance. Concussions result in more than 100,000 emergency department visits for children and adolescents each year, with many more young people with concussion seeking treatment through physicians’ offices or not at all. Timely and accurate identification and management of these injuries is especially important in children and adolescents because diagnosis rates have been increasing in high school sports. Research suggests that adolescents not only are more vulnerable to brain injuries of all severity levels than adults but also may take longer to recover. There is a dearth of literature on vulnerability to brain injury and outcome in even younger youth. Increased susceptibility to concussion and its effects may be because of less-developed neck muscles for stability, hormonal influences, or greater vulnerability during neural development, but there is also something to be said about maturity level and the child’s or adolescent’s ability to follow treatment recommendations. Young individuals have multiple adults who interact with and care for them throughout each day, such as parents, teachers, guidance counselors, coaches, and athletic trainers. When there is a brain injury of any severity, these individuals must be united in their efforts to bring the young student athlete back to health and full participation in academic, sports, and recreational activities.
Physiologic Effects of Concussion
A basic understanding of the underlying physiologic effects of concussive injury to the brain is helpful in directing treatment efforts for the student in school. Acceleration and deceleration forces shake the brain inside the skull, setting off a complex cascade of shifts in ionic concentrations, release of excitatory amino acids, altered brain glucose metabolism, lactate accumulation, and reduced cerebral blood flow, along with temporary disruptions in neural membranes that, together, result in impaired connectivity, changes in neurotransmission, and a veritable energy crisis. These neurophysiologic changes can be understood as a neurologic “software” problem rather than a “hardware” problem; current evidence suggests that concussive injuries rarely result in identifiable cell death or other structural changes. When the neural software is impaired, the brain attempts to return to its normal state, temporarily forced to use a less-efficient anabolic metabolism. The clinical signs and symptoms of concussion are believed to be direct manifestations of this underlying neurometabolic cascade. Any additional activity the individual undertakes, whether physical or cognitive, becomes a source of additional neurometabolic demand on the fragile recovering brain system. If that activity becomes excessive, the cycle of inadequate metabolism and energy is perpetuated, and symptoms worsen. Indefinite prolonging of this energy crisis may have additional consequences to neuronal integrity. Therefore, activity levels must be carefully managed in students to facilitate a fast and effective recovery.
Recovery from concussion
Recovery from concussion is a process along dual continua of severity and time. Severity is multidimensional and includes not only the number and type of symptoms but also the individual’s sensitivity to physical and cognitive exertion. Time can be defined in terms of early postinjury (usually the first few days) and later weeks. There are multiple preinjury and injury characteristics that have been found to influence recovery time. Although concussion has obvious effects on learning (eg, reduced energy level, concentration, and short-term memory), there is also increasing evidence that using a concussed brain to learn can worsen concussion symptoms and perhaps even prolong recovery.
Determining the end point of recovery from a concussive injury is multifaceted and includes several criteria: return of neurocognitive functioning to preinjury levels, return of balance function to preinjury levels, absence of symptoms (or return to preinjury levels) when the individual is at rest, and absence of symptoms when the individual engages in physical or cognitive activity. Each facet of recovery may resolve along a different time line. For example, some individuals report symptom resolution but continue to demonstrate cognitive impairment on neuropsychological testing and/or ongoing metabolic abnormalities. Recovery time is highly variable, from days to weeks to months, and is not easily predicted at the time of injury. For example, some studies of high school and college athletes (mostly football players) report recovery of symptoms and neurocognitive functioning within about 7 to 10 days, yet other studies document a substantial proportion of athletes who continue to experience symptoms and/or neurocognitive impairment well beyond this period.
Multiple factors interact to influence recovery, including premorbid characteristics, the type of sport and/or mechanism of injury, and the age and gender of the individual. Research on predictors of prolonged recovery has been growing, and there is clear evidence that several preinjury and injury factors may prolong recovery, such as premorbid learning disability or attention-deficit/hyperactivity disorder, anxiety or depression, experience of headache, presence of amnesia or loss of consciousness, or previous concussion.
Effects of Concussion on Learning
Concussion has both direct and indirect, and often striking, effects on learning. The symptoms themselves can make efficient processing difficult. The physical/somatic symptoms of concussion, including headache, blurry vision, light/noise sensitivity, and fatigue, can affect a student’s ability to function in the classroom. Sleep disruption during childhood and adolescence is related to cognitive, behavioral, and mood changes, and sleep disturbance is not uncommon after concussion. In addition, difficulty falling asleep and increased need for sleep can make staying awake and alert in class difficult.
A relatively understudied but important phenomenon is the impact of emotional symptoms on learning after a concussion. Clinical experience indicates that anxiety can be both a direct and indirect effect of concussion, and anxiety symptoms can further impair cognitive functioning as well as interfere with students’ compliance with treatment recommendations. Adolescents in particular have a tendency to try to “work through” their symptoms because the stress associated with missing class or not completing their work can seem, in the short term, more unbearable than the symptoms. In addition, experiencing prolonged recovery can lead to or exacerbate emotional symptoms (eg, frustration, anxiety, depression), which may in turn negatively affect individuals’ perception of their cognitive functioning.
The cognitive symptoms of concussion include feeling foggy or slowed down and difficulty concentrating or remembering. There are also measurable effects of concussion on cognitive functioning, including decreased learning and memory, decreased attention, and slowed processing speed and reaction time.
Effects of Learning on Concussion
In addition to the cognitive symptoms that are often experienced after concussion, engaging in cognitive activity (eg, attending class, reading, studying) is hypothesized to stress the already underenergized brain, resulting in worsening of symptoms and potentially prolonged recovery. The experience of worsening symptoms following cognitive activity has been referred to as the effects of cognitive exertion, although it may be more appropriately termed as the effects of cognitive over-exertion. In fact, the concept of cognitive exertion can be represented on a continuum that ranges from no activity (ie, full rest) to full activity (ie, no rest). The therapeutic goal during concussion recovery is to find an appropriate level of cognitive exertion that does not exacerbate symptoms or cause the reemergence of previously resolved symptoms. It is unlikely that this goal would entail complete rest, but instead a level of cognitive activity that is below one’s symptom threshold (ie, subsymptom threshold).
Cognitive overexertion is very commonly reported in clinical settings, and its prevention is of utmost importance. In a group of students who sustained concussions and were treated in the authors’ clinic ( n = 72), more than 80% reported increased postconcussion symptoms after cognitive exertion 1 month after injury. In contrast, in this sample of students, less than 40% reported an increase in symptoms with physical exertion. One factor contributing to this difference was the greater number of restrictions placed on students’ physical activity (43% reported restrictions) versus their cognitive activity (only 3% reported restrictions).
The antidote to cognitive overexertion is cognitive rest, which has been identified as one of the cornerstones of concussion management and involves avoiding excessive demand on neurometabolic processes associated with cognitive activities. Similar to the instructions a physician would provide to an athlete to avoid bearing weight on an injured ankle or knee to promote recovery, the concept of cognitive rest involves avoidance of mental challenges during the initial postconcussion stage. A careful balance between cognitive activity and rest is paramount in these early stages of recovery and beyond. Children and adolescents, with the help of adults involved in their care, should maintain a level of cognitive activity that does not make symptoms worse or reappear to avoid exacerbating symptoms and possibly delaying recovery.
The level of activity that is tolerable (ie, does not worsen or create symptoms) is unique for every individual and changes throughout the course of the recovery time line, both as time passes and symptoms resolve or change, and as the individual’s sensitivity to activity changes. For example, for a highly symptomatic individual in the early stages of recovery who is sensitive to environmental stimuli (eg, noise, light), rest may mean lying in a dark quiet room. Particularly early on, cognitive rest may require a student to refrain from almost all activities that involve cognitive exertion, such as working on a computer, watching television, using a cell phone, reading, playing video games, text messaging, or listening to loud music. Some student athletes may need a full- or part-time hiatus from school while symptomatic. For another individual further along in recovery who is less severely symptomatic and less sensitive to environmental stimuli, light reading or short periods of television or listening to music can be relaxing. One challenge in managing activities to reduce symptoms is that many student athletes have difficulty complying with instructions to limit or completely avoid cognitive activities because these activities are routine parts of their day, used to avoid boredom and to communicate with teammates and friends. For parents and other adults managing a child’s activities after a concussion, prescribing and enforcing limitations require striking a careful balance between prioritizing rest while still allowing some activities in short bursts, provided these activities do not make symptoms worse.
Proactive management of activities is likely beneficial for recovery, although prospective studies of activity management and recovery have not been conducted in humans. In rats, early postinjury physical activity (within the first 2 weeks) led to lower learning and memory performance and reduction in plasticity-related proteins, whereas rats that engaged in activity later in recovery showed improved learning and memory. In humans, a retrospective chart review found that higher levels of cognitive and physical activity during recovery were associated with greater neurocognitive deficits and higher symptom reports.
Recovery from concussion
Recovery from concussion is a process along dual continua of severity and time. Severity is multidimensional and includes not only the number and type of symptoms but also the individual’s sensitivity to physical and cognitive exertion. Time can be defined in terms of early postinjury (usually the first few days) and later weeks. There are multiple preinjury and injury characteristics that have been found to influence recovery time. Although concussion has obvious effects on learning (eg, reduced energy level, concentration, and short-term memory), there is also increasing evidence that using a concussed brain to learn can worsen concussion symptoms and perhaps even prolong recovery.
Determining the end point of recovery from a concussive injury is multifaceted and includes several criteria: return of neurocognitive functioning to preinjury levels, return of balance function to preinjury levels, absence of symptoms (or return to preinjury levels) when the individual is at rest, and absence of symptoms when the individual engages in physical or cognitive activity. Each facet of recovery may resolve along a different time line. For example, some individuals report symptom resolution but continue to demonstrate cognitive impairment on neuropsychological testing and/or ongoing metabolic abnormalities. Recovery time is highly variable, from days to weeks to months, and is not easily predicted at the time of injury. For example, some studies of high school and college athletes (mostly football players) report recovery of symptoms and neurocognitive functioning within about 7 to 10 days, yet other studies document a substantial proportion of athletes who continue to experience symptoms and/or neurocognitive impairment well beyond this period.
Multiple factors interact to influence recovery, including premorbid characteristics, the type of sport and/or mechanism of injury, and the age and gender of the individual. Research on predictors of prolonged recovery has been growing, and there is clear evidence that several preinjury and injury factors may prolong recovery, such as premorbid learning disability or attention-deficit/hyperactivity disorder, anxiety or depression, experience of headache, presence of amnesia or loss of consciousness, or previous concussion.
Effects of Concussion on Learning
Concussion has both direct and indirect, and often striking, effects on learning. The symptoms themselves can make efficient processing difficult. The physical/somatic symptoms of concussion, including headache, blurry vision, light/noise sensitivity, and fatigue, can affect a student’s ability to function in the classroom. Sleep disruption during childhood and adolescence is related to cognitive, behavioral, and mood changes, and sleep disturbance is not uncommon after concussion. In addition, difficulty falling asleep and increased need for sleep can make staying awake and alert in class difficult.
A relatively understudied but important phenomenon is the impact of emotional symptoms on learning after a concussion. Clinical experience indicates that anxiety can be both a direct and indirect effect of concussion, and anxiety symptoms can further impair cognitive functioning as well as interfere with students’ compliance with treatment recommendations. Adolescents in particular have a tendency to try to “work through” their symptoms because the stress associated with missing class or not completing their work can seem, in the short term, more unbearable than the symptoms. In addition, experiencing prolonged recovery can lead to or exacerbate emotional symptoms (eg, frustration, anxiety, depression), which may in turn negatively affect individuals’ perception of their cognitive functioning.
The cognitive symptoms of concussion include feeling foggy or slowed down and difficulty concentrating or remembering. There are also measurable effects of concussion on cognitive functioning, including decreased learning and memory, decreased attention, and slowed processing speed and reaction time.
Effects of Learning on Concussion
In addition to the cognitive symptoms that are often experienced after concussion, engaging in cognitive activity (eg, attending class, reading, studying) is hypothesized to stress the already underenergized brain, resulting in worsening of symptoms and potentially prolonged recovery. The experience of worsening symptoms following cognitive activity has been referred to as the effects of cognitive exertion, although it may be more appropriately termed as the effects of cognitive over-exertion. In fact, the concept of cognitive exertion can be represented on a continuum that ranges from no activity (ie, full rest) to full activity (ie, no rest). The therapeutic goal during concussion recovery is to find an appropriate level of cognitive exertion that does not exacerbate symptoms or cause the reemergence of previously resolved symptoms. It is unlikely that this goal would entail complete rest, but instead a level of cognitive activity that is below one’s symptom threshold (ie, subsymptom threshold).
Cognitive overexertion is very commonly reported in clinical settings, and its prevention is of utmost importance. In a group of students who sustained concussions and were treated in the authors’ clinic ( n = 72), more than 80% reported increased postconcussion symptoms after cognitive exertion 1 month after injury. In contrast, in this sample of students, less than 40% reported an increase in symptoms with physical exertion. One factor contributing to this difference was the greater number of restrictions placed on students’ physical activity (43% reported restrictions) versus their cognitive activity (only 3% reported restrictions).
The antidote to cognitive overexertion is cognitive rest, which has been identified as one of the cornerstones of concussion management and involves avoiding excessive demand on neurometabolic processes associated with cognitive activities. Similar to the instructions a physician would provide to an athlete to avoid bearing weight on an injured ankle or knee to promote recovery, the concept of cognitive rest involves avoidance of mental challenges during the initial postconcussion stage. A careful balance between cognitive activity and rest is paramount in these early stages of recovery and beyond. Children and adolescents, with the help of adults involved in their care, should maintain a level of cognitive activity that does not make symptoms worse or reappear to avoid exacerbating symptoms and possibly delaying recovery.
The level of activity that is tolerable (ie, does not worsen or create symptoms) is unique for every individual and changes throughout the course of the recovery time line, both as time passes and symptoms resolve or change, and as the individual’s sensitivity to activity changes. For example, for a highly symptomatic individual in the early stages of recovery who is sensitive to environmental stimuli (eg, noise, light), rest may mean lying in a dark quiet room. Particularly early on, cognitive rest may require a student to refrain from almost all activities that involve cognitive exertion, such as working on a computer, watching television, using a cell phone, reading, playing video games, text messaging, or listening to loud music. Some student athletes may need a full- or part-time hiatus from school while symptomatic. For another individual further along in recovery who is less severely symptomatic and less sensitive to environmental stimuli, light reading or short periods of television or listening to music can be relaxing. One challenge in managing activities to reduce symptoms is that many student athletes have difficulty complying with instructions to limit or completely avoid cognitive activities because these activities are routine parts of their day, used to avoid boredom and to communicate with teammates and friends. For parents and other adults managing a child’s activities after a concussion, prescribing and enforcing limitations require striking a careful balance between prioritizing rest while still allowing some activities in short bursts, provided these activities do not make symptoms worse.
Proactive management of activities is likely beneficial for recovery, although prospective studies of activity management and recovery have not been conducted in humans. In rats, early postinjury physical activity (within the first 2 weeks) led to lower learning and memory performance and reduction in plasticity-related proteins, whereas rats that engaged in activity later in recovery showed improved learning and memory. In humans, a retrospective chart review found that higher levels of cognitive and physical activity during recovery were associated with greater neurocognitive deficits and higher symptom reports.
Return to activities following a concussion
Return to Cognitive Activity
Concussion management guidelines have begun to appreciate the effects of cognitive exertion on concussion symptoms and management, and the process of academic return is gaining attention in scientific literature, the press, and legislation. Careful management of neurometabolic demands on the brain during recovery, including what is needed for cognitive activity, must avoid exceeding the threshold that produces symptom exacerbation. Children and adolescents spend most of each day engaging in cognitive activity, from classroom work and note taking to homework, and from video games to texting and social networking. Although some of these activities take place at home, many of them occur in the school environment. Thus, school personnel must play an important role in managing these cognitive activities to facilitate concussion recovery. A school with concussion policies and procedures implemented before a student sustains an injury is better prepared to manage a successful return. The basic components of a school-based concussion management plan, including who should be involved and appropriate interventions, are outlined in the following section. Although there is no plan that works for everyone, there are certain symptom and neurocognitive presentations that indicate a need for accommodations, and these are discussed in more detail in the final section of this article.
Return to Physical Activity
Students with a concussion must be restricted from physical activity, sports, and playground activity until a health care professional with expertise in concussion evaluation and management provides clearance for the student to return to play. This restriction is to first protect the student athlete from sustaining another blow to the head and already more vulnerable brain. A second blow can lead to catastrophic injury or, at the very least, significant worsening of symptoms and/or considerably prolonged recovery. Another reason for restricting activity is that physical activity can cause symptoms to worsen during the early stages of recovery. Protocols for returning to physical activity, including recess, physical education (PE) class, recreation, and sports, include graduated steps to increase activity levels while ensuring that symptoms do not worsen or return at each step before progressing to the next level.
The gradual return-to-play protocol for sports activity typically begins after complete resolution of symptoms at physical rest and no symptom return with cognitive exertion. It is essential that school and medical personnel communicate with coaches, PE teachers, and athletic trainers about the student’s cognitive progress when planning a return to physical activity. Students should be able to participate in their typical academic activities, including attending full days of school and completing work without accommodations, with no return of symptoms, before return to play is considered. This provides important information about the postconcussion neurometabolic status of the student athlete’s brain.
At the 2001 Vienna consensus meeting of the International Concussion in Sport Group, concussion recovery strategies focused on a graduated program of return to physical activity. Athletic trainers and sports medicine physicians have been instrumental in promoting and facilitating these protocols. General guidance for having a student athlete return to sports, PE class, or recess may include transitioning the injured student from no participation to limited participation, by gradually engaging only in low-risk drills or activities or playing with increased adult supervision. The gradual return to play in sports takes place in 5 progressive steps, with careful monitoring for return of any post-concussive symptoms at each stage. The first step begins with light physical activity not involving any jarring of the head (eg, walking, elliptical, or stationary bicycle) for relatively short periods. The second step involves an increase in the intensity and duration of activity, introducing movement such as jogging and sports-specific drills. The third step continues to increase the intensity and duration of physical activity incorporating movement in all 3 planes (forward-backward, side-to-side, and up-and-down). Choice of activities in each of the first 3 steps should be made with minimal risk of reinjury. The fourth step involves the athlete participating in controlled scrimmages or other supervised contact play. The final step is participation in full contact competition, where appropriate. Return to play for nonathletes, for whom a systematic plan of gradual return is not readily built in, necessitates a more creative program that might be conducted by an athletic trainer or sports physical therapist to ensure that engaging in physically challenging activities does not result in return of symptoms.
Related posts:
The Pathophysiology of Concussions in Youth
Sport-Related Concussion: On-Field and Sideline Assessment
Subacute Concussion-Related Symptoms in Youth
Long-Term Consequences: Effects on Normal Development Profile After Concussion
Youth Sports and Concussions: Preventing Preventable Brain Injuries. One Client, One Cause, and A New Law
Diagnosis of Concussion: The Role of Imaging Now and in the Future
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