Two important groups released information about concussions and youth recently. The Institute of Medicine recently released its Sports-Related Concussions in Youth: Improving the Science, Changing the Culture, addressing concussions for the youth (obviously by the title). This was on the heels of the American Academy of Pediatrics release of their second report on concussions, addressing the return-to-learn aspect. I offered some opinions on both of the reports via Twitter, but was really underwhelmed by the information in both documents. It seems to me that even though the car is pointed in the right direction the gas pedal is being confused with the brake pedal. At best I feel the community is driving though the rear-view mirror.
A loyal follower and some time contributor, Dorothy Bedford, a self-described “parent activist in concussion education, awareness and advocacy, and newly retired school board member in Princeton NJ,” has penned the following post regarding return-to-learn and the AAP paper. This is not your typical parent; “I come by the interest in return-to-learn honestly, both from my daughters’ concussion and from the point of view of a school board member – with the opportunity to help protect the brains of all students.”
With all of that said, below is her post. Thank you, Dorothy. As a reminder, the inbox is always open to contributors.
The Pediatricians Weigh In on Returning-to-Learning – A Mixed Review
The American Academy of Pediatrics has released its second major clinical report on concussions. It’s a good first step which will help many pediatricians begin to address the second most important issue in concussion management (after “remove from play,” and before “return to play”). On the other hand, ten pages limits the territory it can cover; there’s little new for the ATC who takes a broad view of concussion recovery; the report wildly underplays the complementary role of the neuropsych, and omits any discussion of some important symptoms. I think the most important contribution this report makes will be nudging school administrators to action, especially those who have been inattentive or resistant to dealing with concussions in the classroom and gradual return to learn. It’s hard to ignore the AAP. I will confess, since its release my reaction has swung up and down with each re-reading. Five days later, I hope this will be a balanced review. I like to keep the conversation open.
“Returning to Learning Following a Concussion” was published on October 27 (full report here: http://pediatrics.aappublications.org/content/early/2013/10/23/peds.2013-2867.full.pdf+html) complementing AAP’s 2010 clinical report on “Sport-Related Concussions in Children and Adolescents”. The lead author on both reports is Dr. Mark Halstead, a specialist in non-operative sports medicine at Washington University in St. Louis. Neuropsychologist Dr. Gerald Gioia of National Children’s Medical Center was a consultant. Dr Gioia is a co-author of the CDC’s Physician’s ACE Return to School form, which should be in the hands of every student athlete and their parents for any concussion-related visit to a doctor (http://www.cdc.gov/concussion/headsup/pdf/ACE_care_plan_school_version_a.pdf ). Six other professional societies have endorsed this report.
For pediatricians in areas with thin or no sports medicine/neuropsych coverage, this report is going to be very important, and it stresses continuing education of all parties with responsibility for a student’s recovery. It also has a decent list of resources and references. The report recommends that pediatricians consider utilizing a collaborative team approach to help a student recovering from concussion: a medical team and two school teams, one for physical activity and one for academics. It introduces a new and useful term to the RTL conversation: “academic adjustments” for short-term needs, in addition to accommodations and modifications. The Tables and Figures are concise and generally present information well, but omit any psychological or psychiatric signs or symptoms (more below). The report even goes so far as to emphasize that a “cookie cutter approach to managing a concussion and a return to the classroom cannot be applied,” due to the highly individual nature of each injury. Good on ya’, mate.
The Less Good:
Cognitive Rest. Give the authors credit for including this statement in the background section. “There is increasing evidence that using a concussed brain to learn may worsen concussion symptoms and perhaps even prolong recovery.” Wow ! Are they recommending rest? But, the report backs off, asserting that “there is insufficient research on the role of cognitive rest, although recent research suggests benefit to the concept of cognitive rest both early and late in the recovery.” And similarly, “Determining the appropriate balance between how much cognitive exertion and rest is needed is the hallmark of the management plan during cognitive recovery.” Say what? Are we resting the kid’s brain, or not? To me, this is neuropsych territory, not a medical judgment, although the report got an endorsement from the National Association of School Psychologists Overall, I think the role of rest, both physical and cognitive, and the evolving nature of appropriate cognitive rest throughout recovery is under-described for a report asserting authority on returning to learning, by definition a cognitive activity.
Too Much Discussion of Extended Cases. The report devotes valuable real-estate covering a very specific situation, the lengthy case requiring that an Individual Education Plan (I.E.P., under the federal IDEA legislation) needs to be set up. Come on: 90 days of elapsed time is very fast to set up an IEP. It’s a big commitment. Mention the possibility and move along, because this report isn’t about those patients. (Note: my own daughter’s PCS was 14 months. This report would not have helped us.) Take the child to a major concussion clinic .
The Critical Omissions.
A better use of the word count would have discussed other possible specialists on the medical team. In the case of a moderately severe concussion (lasting more than ten days), a trip to an optometrist to check for visual convergence issues (the source of blurry vision), or to a qualified physical therapist for vestibular rehab therapy addressing balance/dizziness issues either of which might help overcome school attendance challenges in classrooms and hallways. Finally, the major omission of psychological or psychiatric signs or symptoms in Table 1 (impaired judgement, irritability, labile emotions, depression, or suicidal ideation) is a major disservice to clinical practitioners, families, school personnel, and the children. This report leaves a lot of decisions up to the family, but the psychological symptoms are the hardest for families and administrators to understand, and generally difficult for the student recognize, too. Which is why, contrary to the inclination of the AAP report, many concussion recovery decisions should NOT be left to the family, much less the student. Although concussion-related self-harm is relatively rare, it does exist and deserves mention. It can be brought on by school problems as much as by chronic pain such as concussion migraine. This country is in a youth sports concussion crisis, and responsible adults need to take charge and make decisions NOW appropriate to saving our kids’ brains for the future well-being of our society.
Finally, I can’t help but bring readers attention to what remains the best, most comprehensive guidance on return to learn: Dr. Rosemarie Moser’s 2012 book, “Ahead of the Game: the Parents’ Guide to Youth Sports Concussion,” reviewed elsewhere here at TheConcussionBlog.