BASELINE TESTING &
CONCUSSION MANAGEMENT

Electronics

I would recommend at least limiting if not completely restricting their cell phone use. Very limited texting is ok but not watching any videos on the phone. Watching television (i.e. on a larger screen at typically a distance) is potentially ok, but watching video on a small screen like on a cell or computer at generally very close range (inches to a couple feet) is potentially very taxing on the eyes and brain. It is also important to restrict any visual technology use after dark and close to bedtime. Generally this is always a bad idea but especially so for an injured brain. The principle is to NOT isolate them socially, but direct them to allow both their eyes and brain some rest from the typical extended hours that the average student spends on electronics. Use can be gradually increased back to normal over time following the same type of aggravation of symptoms scale that will be explained later and will be followed in home exercises and drills.

Physical Rest

While we recommend physical rest for the first 24-48 hours, we do NOT recommend forced isolation into a “dark room”. Research and clinical experience has demonstrated that the dark room isolation doesn’t improve recovery rates and often increases anxiety and depression. If the athlete voluntarily chooses to just sleep and remain lethargic during the initial 24-48 hours, let them. That being said beyond the initial 48 hours they should NOT be encouraged to sleep all day, this creates both sick behaviour and disrupts normal sleeping habits.

The most important piece of advice to stress is that until the patient has been evaluated outside of and in addition to the emergency room, it is important to NOT allow your child to return to play or engage in ANY activity which could lead to any type of whiplash type injury or head contact of any kind. Remember a concussion is NOT dangerous. Mismanagement of a concussion and too early a return to play by reliance on symptoms and how the athlete “feels” IS dangerous.

Once we have evaluated your child, depending on the degree of ongoing symptoms we will begin treatment. Treatment may include visual, vestibular or physical rehab. Physical rehab will include spinal exercises and balance exercises and what is typically called a Return to Play Protocol (RTP). This will involve a graded progression through non-contact physical exertion; beginning with light aerobic exercise, followed by moderate levels of aerobic non-contact activity (sport and non-sport specific), followed by heavy levels of non-contact activity (sport and non-sport specific). The athlete must remain symptom free during and through each stage prior to progressing. Symptoms must NOT reappear for a minimum of 24 hours for progression to occur. If symptoms do reappear within that 24 hour period then the athlete will return to the next lowest stage of activity that they were able to maintain symptom free. Once asymptomatic status is achieved through the final stage of RTP we then want to ensure that the athlete has achieved/maintained pre-injury cognitive baselines. At that point they can transition into the controlled setting of a full contact practice. Once they demonstrate normal playing behaviour in unrestricted practice they may return to a game situation.

Cognitive Rest

The physical symptoms of concussion vary greatly such as headache, sleep disturbance, and dizziness. It also produces deficits in short-term memory and learning, attention and multitasking. Based on the severity of symptoms, the overall level of impairment may make full attendance at school impossible or ill-advised. Schoolwork and the school environment can exacerbate symptoms, so the extent of school participation must be carefully considered.

The goal with all aspects of recovery is to be aware of and empathetic and accommodating of symptoms, but not afraid of them. Thus realize that the patient will have diminished endurance to physical and mental tasks. They will NOT be able to maintain their normal level of performance and activity. That being said symptoms do not need to be feared and completely avoided. As we outline in the next section (Treatment) approach activities which elicit symptoms in the following manner; if any activity brings on symptoms allow the student to rest. Generally symptoms of less than 5/10 might be encouraged to be worked through. If through rest they recover from their symptoms within 5 minutes, then they can continue with the activity. If recovery requires more than 5 minutes rest, or exceeds a symptom score of 5/10 then they should stop those activities for the day.

Aggravation of symptoms should not exceed a 5/10 because primarily it will lead to the patient feeling horrible for a day or more. This will sometimes loose the athlete a day in the recovery process. While a limited occurrence of this won’t create permanent harm it will none the less loose them a day of school and rehab. We will advise you through this process.

Some students may require a few academic accommodations and we will be happy to provide written recommendations for your child’s school. Basic accommodations for concussion include notifying teachers of the injury, refraining from gym class and other physical activities, taking breaks to control symptoms (e.g. putting their head down, resting at the nurse’s office etc.), and taking extra time on given tasks. Generally testing prior to full recovery is not a fair evaluation of the students ability and/or knowledge.

When a concussion is severe, additional accommodations may be warranted. Dramatic symptoms and memory impairment may indicate temporary removal from school, enrollment in homebound education, or half day attendance until symptoms improve. In addition, students with sensitivity to light and noise may need to eat lunch in a quiet place, avoid auditorium programs, or wear sunglasses to lessen symptoms. Students with severe memory problems may be unable to learn information as quickly or accurately as before. They may also feel that they have learned information but are unable to recall it. In these cases, it is helpful to provide students with cueing (e.g. multiple choice instead of free recall, note cards that contain useful formulas) or allow them to use appropriate notes or books when completing tests. Cognitive rest can also be increased by simply reducing a student’s overall workload. For example, a 50 item homework assignment could be reduced to 25 items by completing every other item, essays can be shortened, and redundant assignments or items could be eliminated.

Certainly, all accommodations will not be appropriate for all classes or all students. Concussion presentations and severity vary among students and accommodations should be tailored to each case. In the end what must be realized is that this is a concussion is a brain injury and beyond physical limitations cognitive functions such as problem solving, mental calculations, reading and memory tasks can be even more taxing than the physical activity. It may be helpful for you as parents to have a meeting with the guidance counsellor or principal to establish which recommendations could be implemented.