Pediatric patients with concussions have different needs than adults throughout the recovery process. Adolescents, in particular, may take longer to recover from concussion than adults. Initially, relative rest from academic and physical activities is recommended for 24 to 48 hours to allow symptoms to abate. After this time period, physicians should guide the return to activity and return to school process in a staged fashion using published guidelines. Further concussion research in pediatric patients, particularly those younger than high-school age, is needed to advance the management of this special population.
Key points
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Most pediatric patients will recover from their concussion within 4 weeks; however, 10% to 33% will have persistent postconcussive symptoms beyond 4 weeks.
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Guiding the patient and family through the return to full academic demands is an essential part of concussion management in the pediatric population.
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“Cocoon therapy” following concussion is no longer recommended as standard of care. After 24 to 48 hours, graduated supervised exercise can be safe in the adolescent patient.
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Learning disabilities, attention-deficit/hyperactivity disorder, mood, and sleep disorders can result in higher symptom severity scores and require focused attention for successful concussion management.
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Little is known about concussions in young children; however, age-appropriate screening tools should be used when available.
Introduction
Concussion diagnoses are on the increase in the pediatric population owing, in part, to increased sports participation, as well as increased recognition and awareness. By the age of 16, one in 5 pediatric patients will experience a traumatic brain injury (TBI). Most pediatric patients will recover from their concussion within 4 weeks. However, about 10% to 33% of pediatric patients will suffer persistent postconcussive symptoms (PPCS) beyond 4 weeks. Although they present with similar symptoms to their adult counterparts, pediatric patients have unique life circumstances and developmental needs that require consideration to ensure excellent clinical care. Many concussions sustained during childhood and adolescence are sport related; however, accidents and free play account for many concussions sustained by patients less than 18 years of age. Furthermore, primary care providers, particularly pediatricians, are often the first point of clinical contact for concussion management. By developing expertise in the management of concussions, including the return to learn and return to play processes, pediatricians are able to guide most patients to complete recovery, but will ideally have the support of sports medicine physicians for those patients who are not recovering within the first few weeks.
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Return to Learn
Most pediatric patients need to return to the high cognitive demand and workload of school. Guiding the patient and family through this return to full academic demands is an essential part of concussion management in the pediatric population. The timing of cognitive rest may impact the duration of symptoms. A retrospective study in elementary, high-school, and collegiate students showed that nearly 45% returned to the learning environment prematurely, resulting in the recurrence and worsening of concussion symptoms. One study found that pediatric patients starting cognitive rest immediately after concussion recovered more quickly than those who delayed cognitive rest for several days after injury. On the other hand, prescribing strict rest beyond a couple of days has been shown to increase emotional symptoms in adolescents with acute concussion. Current consensus guidelines suggest an initial rest period 24 to 48 hours after injury as symptoms abate, followed by a gradual return to cognitive activity while monitoring for symptom exacerbation is appropriate for pediatric patients. The primary role of the physician is to guide patients after concussion through a gradual return to academic activity while minimizing symptoms, stress, missed tests, makeup work, and unnecessary grade repetition or retention.
There is little evidence to guide recommendations for return to learn, but several reviews and guidelines have outlined common school accommodations to ease the transition. , School accommodations should be patient centered and account for the physical examination findings and symptoms the patient is reporting with examples provided in Box 1 . Visiovestibular symptoms are seen in up to 69% of adolescents and may provoke headaches and dizziness, cause blurry vision, and make it difficult to read or take notes. Autonomic symptoms, such as lightheadedness, can be seen with position changes throughout the school day. Cognitive, sleep, and mood-related symptoms make it difficult to focus on schoolwork. All these difficulties exacerbate PPCS and impair functioning in school. A graded return to learn progression can help guide the injured student to reengage in cognitive activity in the days following a concussion ( Table 1 ). Preexisting conditions and postinjury clinical findings may further complicate the school reentry process and thus are important to note when obtaining the pediatric patient’s medical history ( Box 2 ). , Many of these diagnoses have symptoms that overlap with concussion symptoms and can augment symptom scores, complicating school reentry. Any symptoms present before concussion may worsen during the concussion.
Frequent breaks as needed in quiet areas to rest during class (may need to be scheduled in younger patients).
Limit the number of classes in a day.
Initially limit test taking. Once they return to test taking, limit the number of tests per day. Permit breaks during tests.
Temporary use of sunglasses, dimmed screens, and/or paper printouts.
Temporary use of earplugs/headphones in loud busy places.
Delayed return to gym class or outdoor recess.
Permit initially school reentry to include a listening day without note taking or reading.
Vertical saccades deficits: limit note taking and provide preprinted notes.
Horizontal saccade deficits: Provide larger text font, double-spaced lines, audio books, recorded lectures, movies, and so forth.
Convergence deficits: larger font (size 18), preprinted teachers notes, recorded lectures.
| Stage | Activity | Goal of Stage | |
|---|---|---|---|
| 1 | Physical and cognitive rest | Home and leisure activities during the day that do not increase symptoms (eg, reading, texting, screen time). Minimal physical activity | Gradual return to daily activities |
| 2 | Prepare for school reentry | Subsymptom cognitive activity (eg, light schoolwork at home over shorter stretches of time compared with usual). Social encounters with 1 or 2 friends | Increase tolerance of cognitive work |
| 3 | Back to school | Increase cognitive activity in a school environment with accommodations. Start with 1 h, half days, or every other day school attendance, as needed. Begin with listening-only days, attend less stressful classes, temporarily avoiding music or gym class, or preferential seating as needed. Extra time to complete homework/classwork as needed | Increase academic activities |
| 4 | Normal routine with some restrictions | Back to full days of school (but can be <5 d a week, if needed). Completing as much homework in longer stretches of time as tolerated. Resume tests and quizzes as tolerated, with extended time if needed Allow students to catch up on missed tests or work gradually while working to keep up with learning new material | Return to full academic activities and catch up on missed work |
| 5 | Full reintegration | This should include regular attendance, regular homework, regular tests, extracurricular activities |
Preinjury predictors or effect modifiers of slower clinical recovery from concussion
Female sex
High-school age
Personal or family history of migraine
Personal or family history of mental health problems
Postinjury clinical risk factors for persistent concussion symptoms greater than 1 month
Initial severity of cognitive deficits
Development of subacute headaches
Development of subacute depression
In addition to the psychological stress surrounding return to cognitive work, prolonged time out of school can have detrimental effects on the patient’s social life. Adolescents are highly connected to social media through their mobile devices. In addition, they often require electronic devices to communicate regarding schoolwork. There is no evidence to date to suggest that symptom-limited screen time has detrimental effects on recovery. Therefore, prolonged strict avoidance of all electronic devices is discouraged. Beyond working collaboratively with a multidisciplinary team, physicians should determine each child’s social support and resilience. Physicians should continue to teach the important role these social networks play in the recovery period to school professionals and families. ,
Overall, clear communication with pediatric patients and their caregivers is critical to achieve successful school reentry without significant setbacks. Effective coordination with elementary, middle, and high schools is essential for patients and physicians to implement proposed temporary accommodations. Schools face many barriers to implementing state concussion laws because of lack of resources, and physicians play a key role in educating all stakeholders in the latest understanding of concussion management.
Return to Activity and Sport
The phase of metabolic mismatch following concussion in pediatric patients supports the hypothesis that some initial rest is important for patients in the early stages of physiologic recovery in order to minimize the exacerbation of symptoms. However, the optimal length of rest, including the timing of reintroduction of exercise, is still being explored. There is increasing evidence suggesting that supervised exercise is safe during the acute stages of concussion among adolescent patients. Specifically recommended exercises that are safe include jogging or riding a stationary bicycle in a symptom-limited approach, exercising to the point of new symptom onset or worsening of existing symptoms, but not beyond. “Cocoon therapy,” which is sustained avoidance of all activities following concussion, is no longer recommended as standard of care, because there are data that strict rest for multiple days can increase symptoms and does not improve cognitive performance.
There are also emerging data that exercise not only is safe but also may be beneficial for concussion recovery. One trial of 103 adolescents with acute concussion randomized participants to either exercise or placebo-like stretching protocol. The exercise group recovered faster and did not demonstrate an increased rate of prolonged recovery. Assessment of exercise capacity may be beneficial in concussion prognosis as well, as demonstrated in a randomized controlled trial by Leddy and colleagues, whereby adolescents with a lower heart rate at time of symptom exacerbation during the Buffalo treadmill test were more likely to have PPCS greater than 4 weeks. Thus, using treadmill or bicycle tests may prove to be useful in the initial evaluation of concussion to help guide treatment and offer anticipatory guidance. ,
There is well-established evidence for exercise in patients who have PPCS for greater than 4 weeks in the adult literature, making exercise one of the cornerstones for managing chronic concussion symptoms. Kurowski and colleagues demonstrated in a randomized trial of 30 adolescents that symptom scores improved in the aerobic exercise group compared with a placebo stretching group, although adherence rates for the exercise group were low. A larger retrospective study of adolescents with PPCS showed an exponential reduction in symptoms following initiation of a subsymptom threshold exercise program. One cohort in a tertiary care pediatric concussion program found 59% of patients with PPCS had a normal tolerance for heavy aerobic activity. In these pediatric patients, daily subsymptom aerobic exercise working up to 30 minutes per day, including running, elliptical, exercise bike, and sport-related training and drills, should be encouraged. Patients should be specifically instructed to avoid contact drills, scrimmages, games, and other activities that increase the risk of trauma to the head until they have made a full recovery.
Pediatric patients are often motivated to make a full return to sport as soon as possible. However, coordinating sport reentry with the return to school process is important, because students may sometimes be less motivated to return to academic activities. Return to sport after concussion recovery should be navigated in a staged process similar to the return to learn process ( Table 2 ). , The goal of this staged return to sports progression is to prevent worsening of symptoms as the athlete returns slowly back to full physical activity. Working closely with an interdisciplinary team can assist in timely and safe sport reentry. Athletic trainers are increasingly available to athletes in high schools in the United States. They are skilled in assessing patients and facilitating the transition from stage to stage in the return to activity process. This type of exercise progression can also be used to guide the intensity of exercise for those with PPCS just starting out on their exercise plan.
Related posts:
Epidemiology of Sport-Related Concussion
Biomechanics of Sport-Related Neurological Injury
Rehabilitation of Sport-Related Concussion
Neuroimaging in Sports-Related Concussion
Considerations for Athlete Retirement After Sport-Related Concussion
Future Directions in Sports-Related Concussion Management
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