Returning to learning and school performance is arguably the critical centerpiece of child and adolescent development, and there can be significant upset in thinking and understanding after a mild traumatic brain injury, also called a concussion. This injury causes a number of neurochemical changes, which leads to changes in both physical activity and cognitive activity. Additionally, the change in brain chemistry can become a source of additional neurometabolic demand on the brain and may cause symptoms to re-emerge or worsen. Proactive management could facilitate recovery by ensuring less cognitive exertion and stress during the recovery period.
Traumatic brain injury (TBI) of any severity is an adverse event that can threaten the developing child’s future ability to learn. While more severe forms of TBI may be readily recognized as a threat, greater attention is being paid now to both short-term and long-term effects of traumatic brain injury at the milder end of the spectrum. Recent advances in concussion research have provided clinicians with numerous means to recognize and assess mild TBI, commonly known as concussion. It is now widely recognized that neurometabolic dysfunction is a key aspect of a concussive injury, involving a cascade of neurochemical abnormalities following a force to the brain. Historically, physical rest has been the primary focus of attention in treatment for mild TBI. The focus on physical rest alone, however, does not address mental or cognitive exertion, which is essential for the student’s functioning in school. The need for cognitive rest is advocated in the last two international consensus statements on concussion in sport and requires explicit attention in the school setting.
Concussion Basics
Mild traumatic brain injury is defined as a direct or indirect force to the head that results in immediate, short-lived, neurological impairment (e.g., amnesia, loss of consciousness, confusion) that resolves spontaneously, typically followed by physical, cognitive, emotional symptoms and sleep disturbance. Concussions result in more than 100,000 Emergency Department (ED) visits for children and adolescents each year, with many more concussed youth seeking treatment through physicians’ offices or not at all. Timely and accurate identification and management of these injuries is especially important in children and adolescents, as diagnosis rates have been increasing in high school sports. Research suggests that the adolescent age group is not only more vulnerable to brain injuries of all severity levels than adults but that they also may take longer to recover
Increased susceptibility to concussion and its effects may be due to less developed neck muscles for stability, hormonal influences, or greater vulnerability during neural development, but there is also something to be said about maturity level and the child or adolescent’s ability to follow treatment recommendations. Youths have multiple adults who interact with and care for them throughout each day – parents, teachers, guidance counselors, coaches, and athletic trainers. When there is a brain injury of any severity, these individuals must be united in their efforts to bring the young student-athlete back to health and full participation in academic, sports, and recreational activities.
Physiological effects of concussion
Acceleration and deceleration forces shake the brain inside the skull, setting off a complex cascade of shifts in ionic concentrations, release of excitatory amino acids, altered brain glucose metabolism, lactate accumulation, and reduced cerebral blood flow, along with temporary disruptions in neural membranes that, together, result in impaired connectivity, changes in neurotransmission, and a veritable energy crisis. These changes can be understood as a neurological “software” problem rather than a “hardware” problem; current evidence suggests that concussive injuries rarely result in identifiable cell death or other structural changes. When the neural “software” is impaired, the brain attempts to return to its normal state, temporarily forced to use a less efficient anabolic metabolism vs. the normal catabolic metabolism our bodies typically operate. The clinical signs and symptoms of concussion are believed to be direct manifestations of these changes. Any additional activity the individual undertakes, whether physical or cognitive, becomes a source of additional stress on the fragile recovering brain system. If that activity becomes excessive, the cycle of inadequate metabolism and energy is perpetuated, and symptoms worsen. Therefore, activity levels must be carefully managed in students to facilitate a fast and effective recovery.
Effects of concussion on learning
The physical symptoms of concussion, including headache, blurry vision, light/noise sensitivity, and fatigue, can affect a student’s ability to function in the classroom. Sleep disruption during childhood and adolescence is related to cognitive, behavioral, and mood changes, and sleep disturbance is not uncommon following concussion. In addition, difficulty falling asleep and increased need for sleep can make staying awake and alert in class difficult.
Clinical experience indicates that anxiety can be both a direct and indirect effect of concussion, and anxiety symptoms can further impair cognitive functioning as well as interfere with students’ compliance with treatment recommendations. Adolescents in particular have a tendency to try to “work through” their symptoms because the stress associated with missing class or not completing their work can seem, in the short term, more unbearable than the symptoms. In addition, experiencing prolonged recovery can lead to or exacerbate emotional symptoms (e.g., frustration, anxiety, depression), which may in turn negatively affect the individual’s perception of their cognitive functioning The cognitive symptoms of concussion include feeling foggy or slowed down and difficulty concentrating or remembering. There are also measurable effects of concussion on thinking, including decreased learning and memory, decreased attention, and slowed processing speed and reaction time.
In addition to the cognitive symptoms that are often experienced following concussion, engaging in cognitive activity (such as attending class, reading, studying, ability to process and understand) is hypothesized to stress the already poorly functioning brain, resulting in worsening of symptoms and potentially prolonged recovery. The experience of worsening symptoms following cognitive activity has been referred to as the effects of “cognitive over-exertion.” In fact, the concept of cognitive exertion can be represented on a continuum that ranges from no activity (i.e., full rest) to full activity (i.e., no rest). The therapeutic goal during concussion recovery is to find an appropriate level of cognitive exertion that does not exacerbate symptoms or cause the reemergence of previously resolved symptoms.
Proactive management of activities is beneficial for recovery. It is suspected, early post-injury physical activity (within the first two weeks) led to lower learning and memory performance and reduction in plasticity-related proteins, while studies suggest that engagement in activity later in recovery showed improved learning and memory. In humans, a retrospective chart review found that higher levels of cognitive and physical activity during recovery were associated with greater neurocognitive deficits and higher symptom reports.
Conclusions
Athletic return-to-play protocols have been a focus of concussion management for quite awhile, with an emphasis on gradual return to physical activities so that reinjury does not occur prior to full recovery. Legislation regarding the implementation of these protocols has been passed in a growing number of states, making the transition back to sports and recreation both safer and more predictable. In contrast, protocols for return to cognitive activity in school setting are only beginning to gain momentum, and current legislation typically has not included provisions for this process. Whether or not protocols for return to academics are mandated by legislation, to support the recovery and academic needs of the recovering student, systematic efforts must be initiated as soon as possible.
The benefits of active management of cognitive and physical activities are numerous. A well-supported student can focus on resting and recovering without having to spend excess energy on trying to keep up with their academic workload, fighting for accommodations, or becoming anxious about whether their grades will suffer. Although future research is needed, it is possible that proactive management could reduce recovery times by ensuring less cognitive over-exertion and stress – and therefore less misguided energy away from neurometabolic recovery.
