For years, the treatment protocol for children with concussions involved keeping them out of school to rest in a quiet, dark room with reduced access to screens until they felt better. In the past decade, however, doctors have been moving toward encouraging kids to return to school and light activity after only a couple of days of rest, even if symptoms persist.
A recently released study involving more than 1,500 children backs the new approach. It found that an early return to school — which researchers defined as missing less than three days — benefited children ages 8 to 18, who had less severe symptoms two weeks after their concussion compared with kids who stayed home longer. In fact, a longer stay at home seemed to delay recovery.
The idea is to allow children to “maintain as much normalcy and routine as possible, obviously with academic supports and modifications when needed,” said Christopher Vaughan, a neuropsychologist at Children’s National Hospital in Washington who led the study.
Many doctors and institutions have already adopted that treatment plan. “We certainly have changed our protocols to recognize that too much rest is not good, that individuals need to go back to activity as soon as they’re able to tolerate it, with modifications, and that they need to be doing their healing in their environment, which, for children, is school,” said pediatrician Paul Berkner, medical director at the University of New England and president of the Maine Concussion Management Initiative.
The new study “confirms our recommendation, and it gives credence to the fact that they may in fact get better faster if we do that,” he added.
Vaughan said that “around a quarter of the population or more has sustained a concussion, many of which occurred during childhood. The vast majority of people will go on to live healthy and productive lives, but because brain injuries like concussions have the potential to be harmful if not treated properly, we take every injury seriously.”
He teamed up with colleagues from hospitals and universities across Canada to determine whether the number of days a child missed school after a concussion affected their symptoms. The researchers analyzed records from an earlier study of 1,630 children ages 5 to 18 who had been treated for concussion at nine Canadian pediatric emergency departments. There was an equal number of boys and girls, and the concussions were not limited to those caused by sports. Children missed an average of three to five days of school, with younger children on average returning to school earlier than older children.
The study showed “significant” associations between an earlier return to school and improved symptoms for kids 8 and above, and especially for those who initially felt worse. (There was not enough data for a finding involving kids ages 5 to 7.) This led researchers to suggest that a quicker return to school may reduce stress about missed classes and allow a child to stay on a normal sleep schedule and resume light-to-moderate physical activity earlier, all of which they believe will lead to a faster recovery. On the other hand, prolonged activity restriction and isolation, they suggested, could raise risks for anxiety and depression, and being at home could increase screen time.
Berkner said that most parents of patients he has treated haven’t pushed back against the new recommendations. And schools are ready to help.
“Most schools have concussion protocols, both for physical activity and also for academic accommodations,” said Sigrid Wolf, a pediatric sports medicine doctor at Lurie Children’s Hospital in Chicago. In Illinois, each school is required to have a concussion oversight team to assist with providing accommodations such as taking breaks, having extra time on tests or assignments, or reading printed material rather than text on screens.
Although they won’t go to gym class or to recess, they will be encouraged to engage in light activity, such as walking or riding a stationary bike. “Light-to-moderate physical activity also helps kids recover faster from concussions,” Wolf said.
A concussion damages the connections between nerve cells in the brain, which alters how the brain functions until those pathways are repaired. It’s important to give the brain time to rewire itself after a concussion. If a child returns to athletic activities before their brain has healed and sustains another concussion, that second injury could generate more severe symptoms — and, in rare cases, could lead to brain swelling, Wolf said.
But a concussion only raises the risk of subsequent concussions slightly, Wolf said. Furthermore, “each concussion is different. So just because you had a severe concussion the first time doesn’t mean the next time, you’ll have a severe concussion.”
Signs of a concussion fall into five categories, Wolf said: physical symptoms, such as headache, sensitivity to light and sound, neck pain and nausea; vestibular symptoms, such as dizziness and balance problems; cognitive symptoms, such as memory, concentration or processing speed; emotional symptoms, such as irritability and depressed or anxious mood; and sleep and energy symptoms, such as tiredness, increased sleep and difficulty falling or staying asleep.
If a possible concussion has occurred during an activity, it’s important to pull your child off the field or court right away. “We know that kids recover quicker when they’re removed from play immediately,” she said. “Continuing to play for even 15 minutes after you have a head injury is a risk factor for having prolonged concussion symptoms.” The mantra: “If in doubt, pull them out.”
The next step is to consult a health professional, who can help you determine whether your child has a concussion and when your child should return to school; for example, children with a preexisting history of headaches or migraines may require additional support for their return to school, Berkner said.
“We’ve really learned a lot more about concussions and how to treat concussions than we knew even 10 years ago,” Vaughan said. “Many people still believe that engaging in exercise is bad when you have a concussion, but there have been multiple research studies in animals and in humans showing that light noncontact aerobic exercise, usually started just several days after a concussion, is associated with a faster recovery.”
Vaughan and Wolf also said concussion experts are moving away from the preseason baseline cognitive testing that is often conducted by schools and athletic teams, because of doubts about the accuracy of the tests.
When deciding whether a patient should go back to sports, Vaughan focuses on reports from the child and their parents. Signs that a kid is fully recovered include: “They’re not having symptoms at home, they’re not having symptoms when they exercise, their school performance and cognitive functioning appear normal. Their parents see them as being normal again.”
Although doctors want parents to understand the potential severity of concussions, they also want them to take heart in the fact that most children recover within a month.
“We take all brain injury seriously, regardless of what they’re called or how many symptoms show up afterward,” Vaughan said. “Thankfully, many [children] get better relatively quickly. And certainly, if somebody does not do anything to continue to injure their brain during the recovery process, we expect a full recovery and return to normal life activities.”