4 Points that Matter about Post-Concussion Return to Learn

Completely enjoyed learning from Brenda Eagen-Brown- one of the true passionate authorities on post-concussion return to learn, and wanted to share some key "take-away" points from her awesome presentation.

All pictures are from her slides, and comments afterward are mine.

Make sure there is consistent agreement on terms describing what assistance students may receive after a concussion.

Absolutely essential to have all providers ask about these key historical aspects that can and often will impact concussion recovery. If a patient appears to have a more prolonged or difficult post-concussion course, very likely one or more of these items will be a factor. Don't hesitate to ask at multiple encounters as many patients won't initially offer or give sufficient details about pertinent past history.

Great summery of changes that not only teachers should be assessing but also provide the framework for medical providers and families to address classroom difficulties. One of Brenda's key points- recall issues after concussion tend to be difficulties with information retrieval ("on the tip of my tongue") than true memory deficits.

Many benefits to a standing protocol for initial return to learn that doesn't need medical clearance that immediately addresses student need. Extra emphasis on the scheduled rest breaks as waiting until symptoms erupt only slows the recovery process. These efforts attempt to reduce over-stimulation or emotional flooding that more readily occurs during post-concussion recovery as the brain's "filters" are not functioning properly. 

Tips on Dealing with Post-Concussion Headaches

Given that headaches are the most common symptom after concussion and often the last to fully resolve,  I spend a good amount of time with my patients discussing headache triggers, anticipated healing course, and how to reduce intensity and duration. While this post is not intended to make a formal diagnosis or suggest specific treatments, I do hope to share some insights on post-concussion headaches that will help patients, families, and fellow medical providers.

• The location of the headache may be exactly at the point of impact, or perhaps on the different side of head, or even involve the entire head.

• Not uncommon to have all-day headaches right after a concussion. Waking up without a headache should be considered the first sign of improvement. Once that occurs, often headaches will still be daily, but will tend to occur later and later in the day. In the final stages of recovery, the headaches might not be daily, but rather may occur every few days.

• Look at a throbbing headache as a "pop-off valve" warning sign indicating overload of the healing brain.. While this type of headache might be frequently seen immediately after an injury, the evolution of a throbbing headache later in the recovery can indicate excessive activity, such as too much reading/schoolwork, noise exposure, or screen/media time or even a combination of all those factors at one time.  Reviewing and making adjustments in schedules and environments can turn down the cumulative overload and hopefully the throbbing headaches.

• Have found that using the 15-20 minute rule can be quite helpful for patients and families in determining if someone can read/text/play video games/watch TV after a concussion? The goal of course is to not trigger a headache or other symptoms. 
  • Pick one activity (let's say reading to start) and try to do it in a relatively quiet environment for 15-20 minutes. If that time limit is reached without a headache, cool- stop, take a break and maybe come back 30-60 minutes later for another 15-20 minute period of reading. If that second attempt also goes well, then can increase the activity period to 20-30 minutes 2-3 times a day. 
  • If headaches come about before the 15 minutes are up, then stop activity, note the time that passed before the headache began, and after the headache has resolved, try the activity again but stop 1-2 minutes before that past headache onset time.

• If a headache quickly worsens, such as the throbbing headache noted above, an immediate reduction in activity should cause some reduction in intensity. However, in any worsening headache or especially in the case of a "worst headache of my life", one should not hesitate to seek immediate emergency medical evaluation.

While the initial trauma to the head can be a primary cause of post-concussion headache, there can be several other contributors leading to more prolonged and intense symptoms:

• Commonly see a relative muscle imbalance in the suboccipital region where the skull connects to the cervical spine that can be the basis for one-sided or both sided headaches starting "in the back of the head" or with "neck pain". These types of headaches may be more noticed as the patient starts returning to reading, taking notes, and doing other activities that require holding or turning the head for longer periods of time.

• Headaches often associated with dizziness, blurring of words, or double vision that all may increase with reading, screen work, or note-taking could be a result of disordered vestibular-ocular function affecting the visual and balance centers of the brain. 

• Altered sleep patterns, commonly with difficulties either initiating or maintaining sleep, can lead to insufficient rest and an increased in headache duration and intensity. One particular trigger in the post-concussion patient is heightened sensitivity to light emitted from screen devices. Good general rules for all of us (not just post-concussion patients) include no screen devices at least one hour before bedtime and not having screen devices in the bedroom.

• Inadequate food and fluid intake can be a headache trigger for almost anyone, so just imagine how these issues can  be amplified after a concussion. Multiple small meals can be helpful as nausea or diminished appetites are common right after a head injury. Post-concussion dizziness may also be improved with adequate fluid intake, but please do check with your medical provider before increasing or adjusting any type of fluid intake after a concussion.

• Too much noise or too much light, often in combination with each other or with attempts to concentrate. May need to turn off or reduce background sounds, work individually in a quiet room, or use noise-cancelling devices. Reducing ambient lighting, turning down screen intensity, not sitting near windows with bright exterior light, or using regular or blue-light reducing sunglasses can also be helpful.

There are also over-the-counter and prescription medication, vitamin, and herbal supplements that can assist with headaches after a concussion, and I feel that a discussion of these options is best done in direct consultation with a medical provider who has examined the patient and reviewed all aspects of the medical history.

Please let me know of any other tips for dealing with post-concussion headaches.

Taking Control of Your Concussion Recovery

Check out my February post and other great advice at Concussion Connection.

Key excerpt:

“In certain situations, less might be more by building in easier days, rest days, or even off weeks.”

Past shared posts include:

• Sleep, Screen Device Use, and Concussion Recovery
• Knowing Your Resources

Sleep, Screen Device Use, and Concussion Recovery

Each concussion deserves individualized recommendations that seek to strike the delicate balance between a child's need for maintaining social contacts and attempt to continue with school work with a desire to not overwhelm the healing brain and increase post-concussion symptoms. An absolute restriction on screen use might reduce possibility of certain symptoms such as difficulty falling or staying asleep, but can also lead to social isolation contributing to higher symptom reports of anxiety, sadness, and outright depression. 

How can we best strike an appropriate balance between screen use and need for adequate sleep?

Ask most parents if they have worries about sleep issues and amount of electronics/screen device use in their school aged children, and you'll probably get ready nods and smiles of affirmation. 

Ask some of my sports medicine colleagues about why we are seeing more complicated and prolonged post-concussion recoveries, and you'll hear some suggest that the multi-tasking and multiple platforms of communication utilized by smart phones and other screen devices are potential contributing factors.

So since increasing sleep issues and attempts to pry screen-based devices from the hands of kids are common concerns to parents and medical professionals, it should be no surprise that difficulties initiating or maintaining sleep and regulating electronic use are often major challenges in children who have suffered a concussion.

Came across two recent studies on the subject of screen use and sleep that I think shed some interesting light on how we might make recommendations for all children, but particularly in the immediate post-concussion population.

One study from Proceedings of the National Academy of Sciences of the United States of America suggests the use of portable light-emitting devices immediately before bedtime has potential biological effects that may perpetuate sleep deficiency and disrupt circadian rhythms, both of which can have adverse impacts on performance, health, and safety. Such device use can:

•  increase alertness at bedtime, which may lead users to delay bedtime at home
•  suppress levels of the sleep-promoting hormone melatonin,
•  reduce the amount and delays the timing of REM sleep
• and reduce alertness the following morning

While this study used healthy young adults (mean age around 25 years of age), the findings are intriguing enough to be extrapolated to younger patients. Given the frequency where recommended oral melatonin clearly helps with falling and staying asleep, having another pathway to support internal melatonin production can be essential in the recovery process.

An additional study from the journal Pediatrics examined 4th through 7th graders and assessed associations of different screens in sleep environments with sleep duration and perceived insufficient rest or sleep. Particular interest was placed on smartphones which can emit notifications during sleep periods, and relevant findings included:

• Sleeping near a small screen, sleeping with a TV in the room, and more screen time were associated with shorter sleep durations.
• Presence of a small screen, but not a TV, in the sleep environment and screen time were associated with perceived insufficient rest or sleep.

These findings found that small screens could have more adverse effects on sleep than television screens and thus caution against unrestricted screen access in children’s bedrooms for normal, healthy 4th through 7th graders, which again could be extrapolated to include concussed children.

Throwing this all together, a pragmatic approach to screen use after concussion that utilizes the findings of these studies may include the following clinical recommendations:

1) The preponderance of screen devices is an integral reality in the life of many school-aged children and significance of appropriate use cannot be underestimated in expediting post-concussion recovery.

2) Once appropriate, limit screen device time use initially to the middle of the day and not within one hour of any scheduled nap or evening sleep period.

3) All screen device use should be stopped at least one hour before bedtime,

4) Screen devices should be removed from the bedroom to reduce interruptions in sleep from notifications or temptation to check devices for updates during periods of awakening.

Once the child has recovered from the concussion, the child might find that continuing the above screen time recommendations may lead to continued enhanced amount and quality of sleep, which in itself may lead to an enhanced quality of life.

Pre-Concussion Mood Disorders May Lead to Prolonged Post-Concussion Recovery

In an effort to better identify young athletes who might be a greater risk of prolonged recoveries after suffering a sport-related concussion, the findings of a recent retrospective study indicate that a personal or family history of mood disorders maybe linked to a longer recovery period.

Researchers at Vanderbilt University compared athletes who had a three week post-concussion symptom resolution period versus those with a three month or longer symptom recovery period, and found that those with pre-concussion anxiety or depression had a 17-fold increased risk of having the prolonged recovery time.

The research team also found that a family history of mood disorders and delayed onset of symptoms were both also associated with an increased risk of prolonged symptoms after a sport-related concussion.

These findings definitely mirror my experiences in working with school-aged athletes who have suffered concussions during sport activities. 

I am more apt to ask about both personal and family history of mood disorders, often in the initial evaluation after a concussion. I will counsel families that any diagnosed or even suspected pre-existing emotional disorder, including Attention Deficit Disorder with/without Hyperactivity (not evaluated in the above study), depression and anxiety will have a tendency to worsen after concussion. 

In some cases, it is the concussion that makes pre-injury issues more clear and out in the open, and in those instances, we both have to manage the concussion issues but also give proper respect and attention to those underlying mood disorders. 

Early identification and aggressive psychological, medical, and school-based interventions are quite helpful in addressing emotional disorders. Key to have mental health colleagues available to assist in more difficult cases.

Failure to address the mood disorders leads to sub-optimal recovery.

I have also found that those pre-existing emotional disorders optimally managed with appropriate therapy and medication (when indicated) tend to have less consequences or flare-ups after an concussion. 

The findings of delayed onset of symptoms is also not a major surprise. I do tend to see namely depressive symptoms not fully present for up to 4-6 weeks after a concussion. Not sure why this occurs. Could be part of the anticipated physiologic healing response, but could possibly be a by-product of cumulative mental and physical  fatigue that accumulates by this time period and results in higher reported symptom presentations.