If my child’s brain is bruised, don’t we need a CT scan or MRI to confirm that? First, concussions do not involve a bruise to the brain, though children and teens are often told it’s like a bruise” because it’s an easy way to explain a mild injury. Not only is this wrong of course, it also doesn’t help them to understand what this has to do with recommended restrictions, like modified cell phone use! Healthcare providers should instead explain that a concussion involves a metabolic injury, using developmentally appropriate language, in order to facilitate appropriate self-management and compliance with the recovery plan.
How long should my child stay home from school? If your child is too severely symptomatic to go to school initially and just wants to sleep for a couple of days, let them! After that, however, we strongly recommend a return to school with individualized supports to minimize symptom worsening throughout the day.
But my doctor recommended they stay at home until they feel better – who is right? The challenge here is how the word “rest” is interpreted. While current concussion-management guidelines emphasize the need for post-injury rest, rest does not mean staying at home in a dark room with minimal to no stimulation – research and common sense tell us that this makes many children and teens feel worse! Rather, concussion experts increasingly recognize that rest instead means avoiding or modifying activities associated with significant spikes in symptoms, with rest breaks as needed.
But what if my child still feels too poorly to attend school after a few days at home? Again, individualized symptom management is key, guided by professionals with expertise in the management of brain-behavior relationships. This means, for example, an individualized accommodations plan may involve in-class rest and rest between classes, avoiding crowded or noisy hallways, modified workload, etc., so that full days can be tolerated For students with persistent headache, referrals to neurologists with specific expertise in management of post-concussion headache can be particularly helpful in minimizing symptoms and expediting recovery – no need to wait weeks or months just to see if it gets better!
We were told to gradually resume school, with an emphasis on core classes only. Again, who’s right? Even a partial school day can significantly spike symptoms if not managed right (that is, without individualized and symptom-specific management). Moreover, depending on the nature of the instruction and the individual, some “core classes” can be more difficult than others and as such may merit more careful management. Math classes, for example, are usually considered a core class but they typically place the greatest demands on attention and working memory and, as such, merit special considerations.
Why can’t my child take any tests? They’re really stressed about all the make-up tests piling up. Since the sustained attentional focus involved in studying and test-taking can worsen symptoms, and increases in symptoms can impact (impede) test performance and result in lower grades, some providers recommend no test-taking until recovery is complete or nearly complete. However, avoiding tests altogether can be anxiety-provoking for some students and, thus, worsen symptoms too. As with concussion management in general, testing recommendations need to be individualized, based on the test-taker, school, and related factors. In general, I often recommend a modification of tests and testing conditions, with make-ups allowed and tests scheduled strategically, but there is no one-size-fits-all approach that is best for all students.
What about removing electronics? My child’s phone is his/her lifeline to friends! Again, the key is minimizing activities that significantly spike symptoms, and helping your child to understand that. No child or teen understands what phone restrictions have to do with a brain bruise, as they’re often told, but they can understand and apply knowledge of what happens to their brain metabolically with a concussion. The issue with phones is that staring at small, bright, flickering screens for long uninterrupted periods of time can spike symptoms. So, I instead recommend stopping phone use at the point just before symptoms typically spike (often after about 10 minutes initially), taking a break, and then resuming phone use (with brightness turned down) in order to avoid symptom increases.
What is a passing score on ImPACT? There is no such thing. ImPACT can be part of an evaluation to help determine when recovery is complete by providing scores/patterns that suggest that an individual has returned to pre-injury levels of functioning. Those levels will vary across individuals, ages, and learning-related skills, with other factors such as time of day, context, motivation, anxiety, attention, mood, exercise and sleep all impacting baseline and post-injury testing.
But what if my child did not have baseline testing? How else would we know when he or she is recovered? Current international guidelines regarding concussion management do not recommend wholesale baseline testing for a variety of reasons. Testing in large groups by persons not trained in the science of neuropsychological testing, in non-standardized conditions (such as home or large group settings), and outside the age range for which the test was developed have all been highly problematic and often generates less-than reliable or valid scores. This, in turn, makes comparisons with baseline scores” to determine recovery highly risky. Moreover, baseline testing should only be 1 part of a comprehensive evaluation to determine recovery. Although neuropsychological testing has long been regarded as a “cornerstone of concussion management,” not only does this meant that neuropsychological testing should be interpreted by neuropsychologists with explicit training in concussion (not general TBI) management, most children and teens do not need batteries of tests, and frequent re-testing, in order to facilitate recovery.
How long does recovery take? Recovery depends on a variety of factors, including contextual and individual pre- and post-injury risk factors that can prolong recovery. Unfortunately, poor post-injury management (e.g., prolonged home/bed rest, prolonged partial school return, absence of individualized home- and school-based supports, and prolonged post-injury headache, dizziness, and/or anxiety) is the most common reason I see prolonged recoveries in the individuals referred to me who invariably demonstrate specific risk factors that warrant referrals to related specialists to facilitate recovery – such as cognitive-behavioral psychologists to manage the combined impact of pre-injury anxiety and post-injury pain management, highly specialized physical therapists with expertise in post-concussion vestibular therapy, neurologists who specialize in post-concussion headache or vestibular/oculomotor impairment, and sports medicine professionals who can assess musculoskeletal and vestibular/oculomotor functioning.
So which kind of professional is best? There is no one kind of healthcare specialist who has the requisite training or expertise to evaluate or manage all aspects of a concussion. In general, you do want include individuals with explicit training in brain-behavior relationships.
How do we know if the physical therapist we are seeing has the right kind of training? A few things to look for:
- Did the evaluation include assessment of eye movement patterns and balance, and possible musculoskeletal factors that could be contributing to headache?
- Was a home exercise program (HEP) prescribed that includes a series of exercises to be completed a few times/day, in addition to light physical activity?
- Were you given guidance on what to do if symptoms worsen with the HEP, and how much symptom increase is too much?
- When the HEP is completed daily as recommended, is there improvement demonstrated on follow-up visits (typically once or twice/week) and if not, is the PT recommending referrals to other professionals?
- Is the PT communicating with other healthcare providers involved in care?
- Does the PT provide a formal, written return-to-play / return-to-sport protocol for helping determine complete recovery?
- Is the PT anticipating complete recovery in 6-8 weeks for individuals with fairly uncomplicated injuries, minimal risk factors and good compliance, or longer when the injury is more complex, with goals and a plan of care in all cases specific to the individual’s impairments, goals, and pre-injury functioning?
When is it too soon” to see a neuropsychologist or neurologist? Never! We love seeing individuals sooner vs. later in order to facilitate appropriate care and recovery from the outset.
We’ve been told you can’t return to sports until recovery is complete, but we’ve also been told to exercise – which is right? Both! First and foremost, there is no return to any kind of activity or sport with any risk of contact to the head until recovery is complete and the individual has received written documentation of such from a trained healthcare professional. However, we also are learning that active recoveries can facilitate healing. So, in order to achieve the right balance, guidance from a trained healthcare provider is key. Not only does this involve guidance in which sports seem safe, you also want to be sure to minimize activities that can lead to injury-specific symptom increases, such as spikes in heart rate in the acute stages, or rapid head/positional changes when vestibular symptoms are prolonged. Contextual factors are also important considerations – for example, tossing a baseball into a net may be ok, but throwing practice in a field with teammates while balls are flying all around often is not.
At what point do we need to consider a 504 Plan? This, too, varies. 504 Plans are provided to public school students with diagnosed disabilities associated with functional impairments for which accommodations are needed in order for them to be able to function as well as most people. Since concussions are acute injuries, like pneumonia or a broken arm, 504 Plans don’t technically apply, though many schools find this is the best mechanism for providing the supports that are needed to facilitate recovery, and especially when recoveries are prolonged due to associated risk factors. The challenge, however, is that post-concussion supports need to be provided immediately post-injury, and gradually adjusted / tapered off over a period of time (typically not to exceed a couple of months for complicated recoveries) as recovery progresses. In some schools, the 504 team does not have the resources to be able to respond as quickly or nimbly. The bottom line is that no one solution fits all students, schools, or situations, and I simply recommend whatever mechanism best ensures the supports that your student needs to recover, while minimizing the short- and longer-term academic impact.
How do we know when recovery is complete? When the individual has returned to pre-injury functioning without any medications prescribed to manage post-injury symptoms. That is, he or she has resumed a full academic load – full classes, full homework load, transitions/lunch as usual – even if all work is not yet made-up, symptoms have returned to pre-injury levels, and has completed a supervised protocol of physical exertion (“Return-to-Play” protocol), regardless of whether or not a return to team sports is involved, without any symptom recurrence. Note, too, that deconditioning can be a factor in determining how quickly an athlete can return to team sports even after formal medical clearance.
What about nutrition and recommendations to increase carbohydrates? While we know that concussions involve metabolic disruption, there is absolutely no evidence that increased carbohydrates create increased fuel sources that minimize symptoms or speed up recovery! As always, balanced nutrition is best for optimal health and functioning, with adequate hydration particularly important, and especially when headaches are a problem. There is simply no substitute for adequate hydration or sleep.
How worried should we be about CTE? CTE is a controversial topic and it cannot be diagnosed prior to time of death. For additional information see the CTE Handout provided by the Sports Neuropsychology Society.
For additional questions/answers on related topics, see my Blog — http://ganeuropsych.com/blog/