In recent years, increased awareness about properly treating sports concussion has helped standardize the rules around “Return to Play,” and thankfully kept athletes from suffering permanent brain damage. Not true, however, when it comes to the ad hoc approach regarding when athletes are ready to return to the classroom.
Standardization of “Return to Play” rules in Texas and across the country was long overdue. Today, virtually everyone associated with the well-being of student-athletes – from parents and athletic trainers to administrators and teachers – have some idea about how to manage athletes who suffered concussion, back to the playing field.
But what are the rules for “cognitive rest” so student-athletes who suffered a concussion can get back to the classroom fully functioning mentally – able to read, take tests, do homework and participate in other extracurricular school activities?
The goals here – whether it is gradually returning a student-athlete to competition or to the classroom – are not mutually exclusive. We need clear rules for both because too much mental activity can prolong concussion recovery just as much as prematurely returning the athlete to physical activity.
The concept of “cognitive rest” is not new. It was introduced in 2004 in Prague at the Second International Conference on Concussion in Sport. The summary and agreement statement from that meeting recognized cognitive rest as “a need to limit exertion with activities of daily living and to limit scholastic activities while symptomatic.” Furthermore, “During this period of recovery in the first few days after an injury, it is important to emphasize to the athlete that physical and cognitive rest is required.”
Yet, a decade after the Prague Conference, no standardized rules exist for cognitive rest to guide schools in Texas or elsewhere. Although some schools have developed their own protocols and effectively work with students on school re-entry issues following concussion, others make no “cognitive rest” accommodations to ease student-athletes back to the classroom. The consequence of this scattered approach could prolong concussion recovery, and in some cases exacerbate it.
Absent some set criteria, when a student-athlete suffers a concussion, the athletic trainer or coach will declare “No PE, practice or game action for this kid…,” but teachers, administrators, parents and even the athlete may not know he or she needs to rest the brain.
Meanwhile, the student may be suffering cognitive deficits or severe symptoms from taking tests or doing regular class work with no one determining if they were cognitively fit to be in the classroom.
The tricky thing is there is no “one size fits all” approach. Cognitive rest is very individualized. When a concussion occurs, parents need to go to a provider that has expertise in concussion management and knows which modifications are appropriate and the time frame required for implementation.
While there is no hard and fast criteria for what cognitive rest entails, experts recommend that a student who has suffered concussion, “limit activities that require attention and concentration, such as reading, text messaging, playing video games, working online, and performing schoolwork.”
Cognitive rest may also mean that the student only goes to school half days, gradually working toward attending full days again. Providers can help parents identify the specific cognitive deficits in their child post-concussion and serve as their liaison back to the school to help prescribe the types of adjustments needed to facilitate cognitive rest.
It’s important to note, not every student-athlete who suffers concussion will have the same accommodations, or any adjustments at all, because all concussion symptoms are not equal.
One athlete may be experiencing mild symptoms and may just need extra time completing class work. Conversely, another athlete may be so symptomatic and impaired on cognitive testing that they can’t go to school, and if they can, only for a couple hours – with no tests.
Now, will some student-athletes attempt to game the system to get days off or avoid their work load? Yes, just as some will try whether it’s a physical injury or a concussion. As a provider who understands and treats concussion daily, I will call out a student if I think there is some gaming.
That’s why post injury neurocognitive testing is important as a key measure in helping to determine an athlete’s cognitive level following concussion. Properly assessing when a student- athlete is able to return to the class assures school administrators and teachers that cognitive rest accommodations are necessary when they are prescribed by a provider.
So how do schools move forward on this important issue?
A first step towards standardization of cognitive rest is schools developing rules. How? Encourage – perhaps even require – administrators, guidance counselors and teachers to go through concussion education and training just as coaches, athletic trainers and some school nurses do. Now, there may be nothing to push their participation.
Concussion is an epidemic. In Texas, and across the country, we have made tremendous strides institutionalizing “Return to Play” rules to properly manage student- athletes back to play the sport they love. Now, we must focus on standardizing the protocols around cognitive rest so student-athletes can “Return to Learn.” After all, when the game ends, life goes on.
Ott is a neuropsychologist and assistant professor of the Department of Orthopedics at the UT health science Center at Houston medical school and director of the Memorial Hermann Ironman Sports Medicine Institute Concussion Program.