Return to Learn Just As Important As Return To Sports, Says AAP

Helping a student-athlete make a successful return to learning after a concussion is just as important as ensuring their safe return to sports, and requires a team approach involving parents, health care professionals, and schools, says the American Academy of Pediatrics in a 2013 clinical report. (1)

“Students appear physically normal after a concussion, so it may be difficult for teachers and administrators to understand the extent of the child’s injuries and recognize the potential need for academic adjustments,” said lead author, Mark Halstead, who had previously authored the AAP’s 2010 guidelines for pediatric concussions. (2)

The AAP report contains a host of specific recommendations for pediatricians, including that they:

• Assess the concussed student for a more serious structural or neurologic injury;
• Know how the symptoms of concussion can affect the student in the school setting (see table below), as a thorough understanding of potential problems the student can encounter will help the pediatrician make appropriate recommendations to the school, the student, and student’s family;
• Discuss with patients and parents other potential stressors which may affect symptom reporting, such as:
  • family or relationship problems;
  • pressures from coaches and teammates to return to sports; and/or
  • restriction from participation in important upcoming life events.
• Employ age-appropriate symptom checklists serially to follow a student through their recovery and identify areas that might require more targeted interventions.  
  • Because many of the symptoms reported after concussion may not be unique to concussion (for example, some students may have pre-existing depression, chronic daily or intermittent headaches, learning disabilities, or attention deficit/hyperactivity disorder), further inquiry as to the specific nature of the symptoms reported by the student or observed by the parent may be needed.
  • Different symptoms checklists (5) are recommended for students in seventh grade and up (SCAT3)(6) and for kindergarten to sixth grade (Child-SCAT3) (7)
• Take a careful concussion history to account for any preinjury conditions, especially for those experiencing prolonged postconcussive symptoms, which should be managed concurrently;
• Prescribe adequate physical and cognitive rest, as appropriate, to help minimize a worsening of symptoms and potentially facilitate a quicker recovery without significant disruption to the student’s life;
• Communicate with other members of the multidisciplinary team on an ongoing, as-needed basis to coordinate and facilitate a concussed student’s return to learn (see next section);
• Counsel concussed athletes on the current recommended return to activity progressions.

Concussion symptoms: implications for learning

The report provides helpful information on the potential implications in school for a student experiencing particular concussion symptoms and the kind of adjustments that may be required as a result: 

Sign/Symptom	Potential Implications in School	Potential Adjustments
Headache	Most  common concussion symptom Can distract the student from concentrating Can vary over the course of day May be triggered by various stimuli, such as fluorescent lighting, loud noises, and focusing on tasks	Frequent breaks Identifying aggravators and reducing exposure to them Rests, planned or as needed, in nurses office or quiet area
Dizziness/lightheadedness	May be an indication of injury to vestibular (balance/inner ear) system  May make standing quickly or walking in crowded school hallway challenging Often provoked by visual stimulus (rapid movements, videos, etc) Troubles with various aspects of the school building	Allow student to put head down if symptoms worsen Give student early dismissal from class and extra time to get from class to class to avoid crowded hallways
Visual symptoms: light sensitivity, double vision, blurry vision	Slide presentations Movies Smart boards Computers Artificial lighting Difficulty reading and copying Difficulty paying attention to visual tasks	Reduce exposure to computers, smart boards, and videos Reduce brightness on screens Allow the student to wear a hat or sunglasses in school Consider use of books on tape Turn off fluorescent lights as needed Seat student closer to the center of classroom activities (blurry vision) Cover 1 eye with patch/tape 1 lens if glasses are worn (double vision)
Noise sensitivity	Troubles with various aspects of the school environment Lunchroom Shop classes Music classes (band/choir) Physical education classes Hallways Organized sports practices [Note: a student-athlete should not return to sports until asymptomatic and off all academic accommodations)	Allow the student to have lunch in quiet area with a classmate Limit or avoid band, choir, and shop classes Avoid noisy gyms and organized sports practices/games Consider use of earplugs Give student early dismissal from class and extra time to get from class to class to avoid crowded hallways during pass time
Difficulty concentrating or remembering	Challenges learning new tasks and comprehending new material:  Difficulty with recalling and applying previously learned material Lack of focus in the classroom Troubles with test taking Troubles with standardized testing Reduced ability to take drivers education classes safely.	Avoid testing or completion of major projects during recovery when possible Provide extra time to complete nonstandardized tests Postpone standardized testing (may require that 504 plan is in place) Consider 1 test per day during exam periods Consider the use of preprinted notes, notetaker, scribe, or reader for oral test taking
Sleep disturbances	Excessive fatigue can hamper memory for new or past learning or ability to attend and focus Insufficient sleep can lead to tardiness or excessive absences Difficulty getting to sleep or frequent waking at night may lead to sleeping in class Excessive napping due to fatigue may lead to further disruption of the sleep cycle.	Allow for late start or shortened school day to catch up on sleep Allow rest breaks

Return to Learning Team

The AAP recommends that pediatricians work collaboratively with a multi-disciplinary team consisting of the concussed student and their family, school and other medical personnel and individuals at the child’s school responsible for both the student’s academic schedule and physical activity, to ease the transition back to the school environment and facilitate recovery. 

Multidisciplinary Team to Facilitate “Return to Learn”

Team	Members	Role/Responsibilities
Family team	Students, parents, guardians, grandparents, peers, teammates, and family friends	Enforce rest and reduce stimulation to the student during recovery Parents to decide when the student can return to school; If student athlete experiences symptoms enough to affect his/her ability to concentrate or tolerate stimulation for even up to 30 minutes, student should likely remain at home, where he/she may consider light mental activities, such as watching TV, light reading, and interaction with family, until they provoke symptoms, with computer use, texting, and video games at a minimum; When student can tolerate cognitive activity or stimulation comfortably for approximately 30 to 45 minutes (which the report admits is an “arbitrary cutoff”), parents may consider returning the student back to learning, either through home tutoring or in-school instruction with programming adjustment as needed; As concussion symptoms improve, parents work with school academic team on increasing mental and social activities, as tolerated by the student (such as allowing child to attend social gatherings, watch a game, or return to driving), involving medical team only as needed, apart from follow-up visits; In first few weeks after concussion, parents to follow up with school and their child to assess whether academic adjustments are occurring to minimize worsening of student’s symptoms during early recovery; Parents need to sign release of information for school personnel to coordinate adjustments that may be needed as recommended by the primary care provider.
Medical team	Emergency department, primary care provider, concussion specialist (primary care sports medicine physicians, neurologists, neurosurgeons, as examples), clinical psychologist,neuropsychologist, team and/or school physician	Pediatrician identifies “point person” or case manager to contact at school, and identifies point person in the pediatrician’s office to communicate during the RTL process, obtaining the necessary FERPA and HIPAA permissions; Ideally, at least 1 person on this team is communicating with 1 person from the other teams; Reduces likelihood of a pediatrician’s office receiving frequent phone calls from many individuals about same situation. Physicians learn educational terminology to assist them in being precise in what they are requesting of schools, including difference between “academic adjustments” (non-formalized adjustments made to student’s environment during the typical 1- to 3-week recovery period that do not jeopardize the curriculum or require alterations in standardized testing) “academic accommodations” (used to address longer term needs beyond 3 weeks, which may include standardized testing arrangements, extra time on work, changes in class schedule, and access to grade-level curriculum, but still within the context of regular education and may be formalized in a 504 plan); and “academic modification” (used when considering more prolonged and more permanent changes to an educational plan, necessitating special education with needs specified in an IEP.  [Note: this nomenclature is new; it remains to be seen whether it will prove to be meaningful and useful distinctions for schools and health care practitioners across the U.S. to use.] Pediatrician lists restrictions and adjustments on note to school at each patient follow-up visit and during interim, if needed; Gather data from other team members needed to aid in deciding when to provide the written authorization now required in all states (at least at the high school level) before a concussed student-athlete can begin safe progression back to increasing physical activity leading to a return to sports. For students with symptoms that last longer than three weeks, pediatrician provides school with medical documentation based on persisting signs and symptoms that might significantly limit a child’s ability to access full instruction, and referral to a concussion specialist should also be considered, if not already initiated.
School academic team	Teacher, school counselor, school psychologist, social worker, school nurse, school administrator, school physician	Recognize that most students will likely return to classroom while symptomatic from their concussion, and that return requires individualized approach (no “cookie cutter”); In early phases of a concussion, coordinates return of student to cognitive exertion and helps facilitate appropriate level of academic adjustments necessary to reduce or eliminate symptoms. Most interventions can be made to general education classroom by general education teacher with minimal support and check-ins with other members of academic team; When the student returns to school, observing which classes exacerbate symptoms to allow for further adjustments to help reduce making symptoms worse; Teachers encouraged to pick and choose academic adjustments most amenable to their class teaching style and content and most appropriate for the phase of recovery of the concussion on the basis of a child’s tolerance; Teachers and other academic team members reassess progress at weekly intervals to determine effectiveness and continued need for adjustments, communicating directly with student in a private setting. In cases of prolonged symptoms, activate system for accommodations (504 plan) for students expected to have temporary interference with learning or modifications (IEP) for students with a classifiable chronic condition; Brain storm and problem solve with family and medical teams about what other interventions may be helpful and decide whether more formalized assessments need to occur; at this level some of the interventions can no longer be easily applied in general education classroom without formal intervention (i.e. Individualized Health Plan, learning plan, or 504 plan). If symptoms remain severe or prolonged (typically longer than 5 to 6 months), more intensive intervention may be needed, potentially including considering more permanent disability, triggering in most school districts their Child Find (a component of IDEA) obligations, providing appropriate testing, and development of an IEP in consulation with the family and medical team. Note, however, that is uncommon for the student with a concussion to need an IEP. A medical diagnosis of concussion can prompt the school academic team to collect other sources of information and consider developing a 504 plan or IEP, which are governed by different laws.
School physical activity team	School nurse, athletic trainer, coach, physical education teacher, playground supervisor, school physician	In early stages of the concussion, primary goal is to safeguard student from any further potential injury to the brain (no sports, no PE, etc.) After student no longer needs academic adjustments or  accommodations, begin return to play protocol leading to eventual return to competition.

“We know that children who’ve had a concussion may have trouble learning new material and remembering what they’ve learned, and returning to academics may worsen concussion symptoms,” writes Halstead.

The report said it it was “unfortunate that [so] little attention has been given to academics and learning and how a concussion may affect the young student learner.” 

“Every concussion is unique and symptoms will vary from student to student, so managing a student’s return to the classroom will require an individualized approach,” said Halstead. “The goal is to minimize disruptions to the student’s life and return the student to school as soon as possible, and as symptoms improve, to increase the student’s social, mental and physical activities.”

Research, the report says, has shown that a school-aged student usually recovers from a concussion within three weeks. If symptoms are severe, some students may need to stay home from school after a concussion. If symptoms or mild or tolerable, the parent may consider returning him or her to school, perhaps with some adjustments, says the AAP.

The AAP  calls for an “individualized approach for the student when a pediatrician is making recommendations for cognitive rest and the student’s RTL [return to learning] in the school setting.”

Noting the lack of research documenting the benefits or harm of cognitive rest in either prolonging concussion symptoms or the ultimate outcome for the student following a concussion, the report  says that determining the appropriate balance between how much cognitive exertion and rest is needed is the “hallmark of the management plan during cognitive recovery.”  

Given the disruptive nature that concussion symptoms may pose for the student and his or her family, the report warns against imposing too many restrictions on cognitive and physical activity beyond the first several days after concussion, suggesting that they may not be needed and created the potential for “further emotional stress during the recovery.”

Students with severe or prolonged symptoms lasting more than 3 weeks (the point at which some experts classify a concussed student as having post-concussion syndrome) may require more formalized academic accommodations, the group says.

Delicate balance

While laws may vary by state, writes Halstead and his colleagues, “it remains essential that all  [schools] recognize the importance of team management for a student after concussion and ensure that all students recovering from concussion have assigned staff who will be responsible for smooth re-entry to school.”

“The challenge of the multidisciplinary team is to balance the need for the student to be at school with the appropriate adjustments for the cognitive demands at school that have the potential for increasing symptoms.  To reach the right balance at home and school, the multidisciplinary teams should be well versed in their roles and responsibilities in concussion management and keep communication open among all parties regarding decisions to progress, regress, or hold steady during the RTL process,” says the report. 

“Education regarding concussion generally, and the role of cognitive and physical rest and return to school, specifically, is essential for the teams of individuals helping a student with concussion during assessment, management, and recovery.  This education should extend to both school personnel (eg. administrators, athletic directors, teachers, guidance counselors, school psychologists, coaches, school physicians, school nurses, ATs) and individuals likely not employed by the school (eg. primary physicians, sports/team physicians, emergency department physicians, parents, and other caregivers),” says Halstead.

The challenge is that, even in states with legislation requiring concussion education and management, “nonathletic personnel in schools are often left out of concussion education efforts.”  Taking a comprehensive team approach, suggests the AAP, “may help reduce mistakes in management, which could potentially risk reinjury during the healing phase, lengthen recovery, or result in untoward long-term outcomes.”

Common sense approach to cognitive rest recommended

While, for a time, many clinicians believed that strict cognitive and physical rest until symptoms cleared speeded recovery, the common sense approach to cognitive and physical rest taken by the AAP has, in the three years since the report’s publication, is beginning, despite limited research, to become the consensus view, with recent studies finding that there may be no advantage to strict rest beyond the first 1 to 2 days after injury (8) , and that re-engaging in moderate exercise as soon as possible after injury as long it does not exacerbate symptoms is not only unlikely to have a detrimental effect but may even be beneficial. (9)

In one 2015 study (10), for instance, researchers at the Medical College of Wisconsin reported that strict physical and cognitive rest in the five days immediately after concussion, in fact, did not help teens recover more quickly than taking it easy for one to two days after injury and then returning to school.

Indeed, the group advised to rest for five days actually reported more daily post-concussive symptoms during the first 10 days after their emergency department visit and slower resolution of symptoms than those who rested for 1 to 2 days and then returned to school.

The study was unable to explain the difference in symptom reporting, but noted that it was possible that the discharge instructions influenced the patient’s’ perception of illness, leading them to report more symptoms, and that the deleterious effects of strict rest they observed may have more to do with emotional distress caused by school activity and activity restriction, because missing social interactions and falling behind academically may cause concussed student-athletes to become depressed, increasing physical and emotional symptoms, just as the AAP predicted four years earlier in its 2010 clinical report on concussions, when it suggested that, “adding additional restrictions that may not be needed” had the “potential to create further emotional stress during the recovery.”   

Most recently, a group of concussion experts, after meeting in October 2015 at a conference at the University of Pittsburgh Medical Center sponsored by the National Football League and closed to the press, that strict rest beyond the first few days after a concussion might actually delay recovery.  

“Exercise is a way of treating this,” Dr. Javier Cardenas, a neurologist at the Barrow Concussion and Brain Injury Center in Arizona, told the Pittsburgh Post-Gazette. “Many times, we see patients who are completely restricted from any physical activity. As one of the major sources of this injury is sports and athletics, for those who are involved in athletics, this is actually a punishment. They become depressed. They become anxious. So allowing them to participate in physical activity – while keeping them out of harms’ way, of course – is actually a rehabilitation method.”

Another concussion expert who believes that complete cognitive rest may be over-prescribed is Elizabeth M. Pieroth, Pys. D., a clinical neuropsychologist with North Shore Medical Group in Chicago and a consultant to a number of Chicago professional sports teams, including the Bears, and an unpaid consultant to the National Football League.

Like Dr. Cardenas, Dr. Pieroth saw many of the same downsides to keeping concussed athletes out of school for more than a few days after injury, including social isolation, depression, and an unhealthy focus on symptoms instead of recovery. Reviewing the results of the pediatric studies demonstrating an association with rest and outcome after concussion, the studies, taken together, showed that the “current usual care endorsing modest physical and cognitive rest after injury is an effective strategy for recovery.”

Thus, even with limited research, clinicians are starting to see, as with physical rest, evidence that a more moderate approach [to cognitive rest] is probably ideal for recovery. (11)

---

1. Halstead ME, et al. Council on Sports Medicine and Fitness; Council on School Health: Returning to learning following a concussion.Pediatrics 2013;132(5):949-957

2. Halstead, ME, Walter, K. “Clinical Report – Sport-Related Concussion in Children and Adolescents”  Pediatrics. 2010;126(3):597-615 (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;126/3/597).

3. Rocky Mountain Youth Sports Medicine Institute, Center for Concussion. REAP Guidelines. Available at: http://www.rockymountainhospitalforchildren.com/sports-medicine/concussion-management/reap-guidelines.htm. (accessed June 18, 2013)

4. Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric providers’ self-reported knowledge, practices, and attitudes about concussion. Pediatrics. 2012;130(6):1120-1125.

5. McCrory P, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.  Br J Sports Med 2013;47:250-258.

6. SCAT3. Br J Sports Med 2013;47:259.

7. Child SCAT3. Br J Sports Med 2013;47:263.

8. Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collins MW, Meehan WP. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Pediatrics 2014;133(2):1-6.

9. Leddy J, Hinds A, Sirica D, et al. The role of controlled exercise in concussion management.  PM R 2016;8 (Suppl 3):591-5100.

10. Thomas DG, Apps JN, Hoffman RG, McCrea M, Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics 2015;135(2). DOI:10.1542/peds2014-0966 (e-published ahead of print, January 5, 2015).

11.  Halstead ME, Eagan Brown B, McAvoy K. Cognitive rest following concussions: rethinking ‘cognitive rest.’  Br J Sports Med. 2016;doi:10.1136/brjsports-2016-096674 (epublished September 15, 2016)

For further reading/watching

Few States Regulate Return to Learn, Study Finds
Return to Learn After Concussion: Modify School Environment To Avoid Triggering Symptoms (video)
Return to Class After Concussion Different for Every Student (video)
Academic Accommodations After Concussion (video)
Study Confirms Adverse Effect of Concussion On Academic Learning And Performance of Children and Teens
More Post-Concussion Help For Students In Classroom Needed
Post-Concussion Strategies for the Classroom
Recovering from Concussion: Teachers Play Important Role
New Study Claims Strict Rest After Concussion May Not Speed Recovery