POSTCONCUSSION MANAGEMENT
All concussion management guidelines concur that immediate removal from play of a pediatric athlete with a suspected concussion is the most important initial action. Regardless of how short the duration or mild the symptoms may be, same-day return to play should never occur.3-5 This is particularly true because acute concussion is an evolving injury and manifestation of symptoms, including cognitive deficits, is often delayed.3
The foundation of postconcussion recovery is rest, both physical and cognitive. Acute symptoms must diminish before a gradual resumption of activities.3,5
Cognitive rest
Cognitive rest is the cornerstone of concussion management.5 The latest guidelines stress the importance, particularly in the pediatric age-group, of decreasing any activities of daily living that may aggravate symptoms.3 This includes such common childhood pastimes as playing video games, watching television, and using a computer.15 More important, cognitive rest means academic rest, which is essential to postconcussion recovery and preparing the child for a “return to school” or “return to learn.”21, 22
Return to play
In pediatric concussion management, a conservative approach to the determination of when a concussed child may return to play (RTP) is key. RTP decisions are guided by the resolution of the child’s symptoms and are based on clinical judgment.3-5
Current guidelines outline a gradual, stepwise approach to RTP after full recovery, which must be individualized and age-appropriate.3,5 These include
• Light aerobic exercise: Increase heart rate to 70% maximum predicted by walking, swimming, or using stationary bike. No resistance training.
• Sport-specific exercise: Add movement with skating or running drills. No head impact activities.
• Noncontact training drills: Add exercise, coordination, and cognitive load with progression to more complex training drills (eg, passing drills in football and ice hockey). May introduce progressive resistance training.
• Full contact practice: To restore confidence and allow coaching staff to assess functional skills, permit participation in normal training activities after obtaining medical clearance.
At any step, if symptoms develop with activity, the process is stopped and, after a 24-hour period of rest, is restarted at the previous symptom-free step.3,5
The goal of this approach is to ensure that the pediatric brain recovers fully and can resume normal developmental acquisition of cognitive skills and functions. Further, as previously noted, children and adolescents require more time to recover from the effects of a concussion than adults do.2,3 If a child returns too quickly to activity postconcussion, clinical evidence suggests that worsening of cognitive deficits is likely.9 Therefore, cautious postconcussion management that allows sufficient recovery time before clearance is given for a return to sports participation is highly recommended.2,4,5 No child should RTP unless cleared by a health care provider trained in the evaluation and management of pediatric concussive injuries.4,5,15
Return to school
Inadequate knowledge of concussion on the part of parents, teachers, and school officials can be a barrier to appropriate return-to-school decisions after pediatric concussive injuries.22 Since pre–high-school-age children spend the majority of their time in school, it is essential that a child’s school attendance and workload demands be decreased during recovery from a concussion.
Evidence indicates that an increase in cognitive or physical activity before complete recovery—ie, before normal brain cellular function is restored—may prolong cognitive dysfunction.5 Arbogast et al found that, in many pediatric concussion patients, unresolved symptoms impeded learning and school-based functioning: 10% to 18% of the children studied experienced fatigue, difficulty concentrating, feeling foggy, and/or vision problems.21 Within the first two weeks postinjury, 80% reported an increase in symptom severity while at school.
Academic demands should be increased gradually, with adjustments made for the individual student as needed, in order to avoid the exacerbation of such school-setting symptoms as headache, dizziness, light and/or noise sensitivity, and difficulty concentrating or remembering.22
While RTP guidelines are widely understood and implemented by clinicians, one survey found that return-to-school guidance is provided less often.21 Clinicians should be mindful of the importance of both physical rest and cognitive rest during recovery from pediatric concussion and should provide parents with clear guidance for both.21
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