Last week I blogged about head injury and the differences that can be observed between cases of mild head trauma and moderate to severe head injury.

Today as a follow on, I wanted to write about returning to school and sport after a traumatic head injury.  It is actually not well known that children need to eased back into their normal activities.  We commonly see that allowing kids to do too much too soon after a head injury, can cause a whole lot of problems.

For most kids, the symptoms of a mild head injury resolve within three weeks of the accident.  These symptoms might include:

• Headaches
• Troubles with maintaining attention
• Fatigue
• Increased irritability or moodiness/tearfulness
• Having a longer processing time or having difficulty with coming up with responses
• Photophobia and phonophobia (fear of light and noise)

 

But how much is too much? And how do we go about balancing the need for rest, with encouraging their return to normal activity in order to avoid mood disturbances or social withdrawal?

Gahhhh…. Why is everything so hard?! 

Never fear, here is some practical advice:

It is important to note that usually complete brain rest (from all activities that require or stimulate brain activity) is recommended for the first 1-2 days following an injury.  This includes a complete break from video/computer games, iPad/iPhone use, texting, home/school work, reading, going out for dinner).  This is critically important because rest enables the brain to recover.  If there is a lot of energy spent on mental exertion (eg trying to study hard for an exam, staying up watching YouTube), then there is less energy available for the brain to use to repair itself.  This can prolong recovery.

When the child is completely without signs of concussion (ie no headache/dizziness/irritability/fatigue etc as listed above) then reintroduction of short periods of activity can occur.  Examples of this might be 10 mins of screen time once or twice a day, going for a short and gentle walk or having a friend visit for an hour or so.  As the child demonstrates that they can tolerate these short activities, then steps can be taken to introduce more challenging or longer tasks.

If your child’s symptoms worsen, then wind the activity back a notch and allow more time before trying to re-introduce more difficult activities.  Often even a graded approach to return to school needs to be individualised to the child and their own rate of recovery.

The tables below are taken from a fact sheet from the RCH Melbourne.  They give a practical and step-wise approach to returning to school and sport. I’ve copied and pasted them here (rather than reinventing the wheel!).

 

RETURNING TO SCHOOL

Only progress to the next step if your child remains symptom free. If you cannot make progress on these steps, slow down (and go back a step) and see your doctor.

 

Step	Goal
1. Daily activities at home Start your child on typical daily activities, such as reading or gentle walking. Begin with 5 to 15 minutes at a time and gradually build up.	A gradual return to typical activities
2. School activities at home Introduce homework, school reading or other educational activities at home.	To increase tolerance to cognitive work
3. Return to school part time Your child may need to start with a shorter school day or have increased breaks during the day. School tests may need to be delayed.	To increase academic activities
4. Return to school full time Gradually increase school activities until your child can tolerate a full day.	Return to full academic activities and catch up on missed work

 

RETURNING TO SPORT

Helpful tips:

• Only start to re-introduce sport, once a child is successfully back at school
• Leave at least 24-48 hours between each step
• Only progress to the next step if your child remains symptom free
• Remember that head injury can make your child slower to react to things, and also slow their processing speed. This can make fast pace sports (like football, road/BMX cycling, motorbike riding, skiing, snowboarding, surfing, scootering, skateboarding, horseriding, climbing trees etc) more risky than usual.

 

Step	Goal
1. Symptom-limited activity Simple daily activities that do not provoke symptoms.	Gradual return to typical activities
2. Light aerobic exercise Gradually introduce walking, swimming or stationary cycling at a slow to medium pace. Do not allow resistance training at this stage.	To gradually increase heart rate
3. Sport-specific exercise Your child can begin activities such as running, warm-up drills and practicing ball skills (with a soft ball). Do not allow any activities that involve head contact.	To add movement
4. Non-contact training drills Introduce harder training drills, such as passing drills. Your child may start progressive training.	To introduce exercise, co-ordination and increased thinking
5. Full contact practice Following medical clearance, participate in normal training activities.	Restoring confidence and allowing coaching staff to asses functional skills
6. Return to sport Your child can now progress to normal game play.	Resume regular sporting activity

There are plenty of fact sheets around for school professionals to help support children returning to school after head injury.  Essentially though, similar rules apply to those in the home so share all relevant medical advice with your child’s teacher and school to support their return to normal activities.

 

In the classroom, strategies can be used to combat

• Fatigue (frequent breaks, reduction of work load, peer note-taker)
• Headaches (allow child to move to a quiet area, provision of pain relief as needed at school as recommended by your child’s doctor)
• Noise/light sensitivity (limiting noisy classes eg manual arts, assembly PE)
• Slowed cognitive processes (allow extra time to complete tasks, allow breaks, one step instructions)

Talk to your child’s teacher about what can be done to ensure that it is done or made available to your child as they return to school.

 

Take home messages:

• Most concussions will get better on their own over several days; but some can take weeks
• Don’t rush the return to school and sport (for some children it can take up to 3 months).
• Only move onto the next step if your child does not have worsening/reappearance of symptoms
• Talk to your doctor if you are unsure whether your child is ready for the next stage or if they can fully return to playing their chosen sport (and some sports are higher risk than others)
• Seek urgent medical attention if your child’s symptoms get worse or they develop new symptoms of concussion.

I hope you have found these posts on head injury useful, but I sincerely hope you don’t ever have to use them!

 

Till next time, stay well and MAKE YOUR KIDS WEAR HELMETS!!!!

xxDr Megs