Medical Treatment of Concussion Justin M. Wright, M.D., CAQ-Sports Medicine1
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
ABSTRACT
A concussion is a brain injury, a change in function induced by traumatic forces. The incidence of concussion is increasing, likely due to increased awareness and improvement in recognition. Speech and language pathology professionals working in schools may encounter patients who have suffered concussions. At the root of concussion pathophysiology is altered metabolism and an acquired energy deficit. The mainstay of treatment for concussion is cognitive and physical rest, allowing for normalization of the metabolism and correction of the energy deficit. Once recovered, the student may need accommodations to successfully return to school without added difficulty and should follow a return to play protocol to return to athletics safely. KEYWORDS: Concussion, rest, return to learn, return to play
Learning Outcomes: As a result of this activity, the reader will be able to (1) describe the symptoms of a concussion; (2) describe the mainstay of acute treatment of a concussion; (3) discuss the evidence regarding physical and cognitive rest as treatment for a concussion; (4) describe the steps involved in the return to school for a patient with concussion; (5) describe the steps involved in the return to sports for an athlete with concussion.
T
he incidence of concussion is increasing, likely due to increased awareness and improved recognition of the symptoms.1 As the rate of concussion diagnoses increases, speech and language pathology professionals who work with schools and athletes will likely encounter more patients who have suffered a concussion. Understanding the underlying pathophysiology and appropriate treatment of concussion will
help to hasten recovery and reduce the risk of postconcussion complications. This article will summarize the current evidence available for the acute treatment of concussion. A concussion is a brain injury caused by a direct blow to the head, face, neck, or elsewhere on the body that transmits the force to the head.2 The diagnosis of concussion is a clinical one, relying on a constellation of signs and
1
Concussion 101 for SLPs; Guest Editor, Anthony P. Salvatore, Ph.D., CCC-SLP Semin Speech Lang 2014;35:155–158. Copyright # 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 5844662. DOI: http://dx.doi.org/10.1055/s-0034-1384676. ISSN 0734-0478.
Department of Family and Community Medicine, Paul L. Foster School of Medicine, El Paso, Texas. Address for correspondence: Justin M. Wright, M.D., CAQ-Sports Medicine, Department of Family and Community Medicine, Paul L. Foster School of Medicine, 9849 Kenworthy St, El Paso, TX 79924 (e-mail: Justin. [email protected]).
155
SEMINARS IN SPEECH AND LANGUAGE/VOLUME 35, NUMBER 3
symptoms that are present following a history of trauma. Headache is the most common presenting symptom.3 Other common symptoms include dizziness, balance disturbance, disorientation, photophobia, phonophobia, amnesia, and nausea. Many patients also report temperament changes and/or emotional lability or may complain of a feeling of fogginess and an inability to focus or concentrate.3,4 The object of the physical exam is to exclude more serious injury, such as a cervical spine injury, skull fracture, or intracranial bleed, but findings in a patient with a concussion may include postural instability and cognitive dysfunction (slow responses, inability to remember a series of numbers or to count backward by sevens). The use of neuropsychological testing has been shown to be of clinical value in the evaluation of concussion and is designed to identify subtle cognitive deficits.2,3 Concussion results from a neurometabolic cascade initiated by an impact to the head, face, or body that transmits the force to the head. This impact leads to the release of excitatory neurotransmitters, disruption of cellular membranes, and ionic flux. To correct the ionic imbalance, large amounts of adenosine triphosphate are required, leading to increased consumption of glucose. At the same time, cerebral blood flow is reduced, eventually leading to an energy mismatch and glucose hypometabolism. Trauma-induced calcium influx leads to mitochondrial dysfunction, further worsening glucose utilization. This process of impaired glucose metabolism and mitochondrial function may take up to 5 to 10 days to normalize.5 Recovery from a concussion requires restoration of the energy balance and normalization of the glucose metabolism. This article will discuss the treatments available to improve symptoms and to shorten recovery time from a concussion.
TREATMENT The mainstay of concussion treatment is physical and cognitive rest in the acute period.2 This period of rest includes time off from school; no homework, reading, visually stimulating activities (computers, video games, texting, use of cell phones, and limited or no TV), exercise, athletics, chores that result in perspiration/exer-
2014
tion, trips, or social visits in or out of the home; and increased rest and sleep.6,7 However, this recommendation was initially based on expert opinion, as prior evidence evaluating the effect of rest on concussion was sparse. Exercise and cognitive activity are thought to increase metabolic activity in the brain, which would further worsen the energy mismatch, worsen symptoms, and further delay recovery. Rat models have demonstrated worsened cognitive performance and delayed recovery with early voluntary exercise following a concussive injury.8 A study using functional magnetic resonance imaging in athletes with concussion demonstrated that those who had the most hyperactivation after injury had longer clinical recovery times than those who did not have hyperactivation.9 Several recent studies have examined the effect of rest on concussion recovery. In a retrospective cohort study of 184 athletes who sustained a concussion, the investigators compared those patients who had the recommendation for cognitive rest documented in the chart with those who did not have such a recommendation documented. They found no difference in duration in concussion symptoms between the two groups.10 However, this retrospective study looked only at documented recommendations and did not determine whether the patients actually followed recommendations. Other studies have shown a more favorable response to rest but still have limitations. In a retrospective cohort study by Majerske et al of 95 student athletes who suffered a concussion, each athlete was stratified to one of five activity levels, based on a self-reported postinjury activity intensity scale.11 Progress was followed using computer-based neurocognitive testing and postconcussion symptom score reporting. Those engaged in the highest amount of activity (school activity and participation in a sports game) scored worse on their neurocognitive testing and reported more symptoms than those in the moderate activity group (school activity and light activity at home). Notably, those in the moderate activity group also performed better and reported fewer symptoms than those in the low activity group (no school or exercise activity). The authors point out that initial activity level may be indicative of the severity of the initial injury, with those who suffered
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
156
more severe injuries limiting their activity spontaneously and those with less severe initial concussions continuing their preinjury level of activity, ultimately leading to worsening neurocognitive and symptom scores.11 In another study, 49 high school and collegiate athletes, with time of presentation ranging from 1 day to several months postconcussion, were prescribed 1 week of cognitive and physical rest at the time of their first postconcussion evaluation. At the second postconcussion evaluation, the decision was made either to continue with rest or to transition to school, based on the patient’s current level of symptoms. Twenty-eight of the 49 patients received an additional week of prescribed rest. Progress was monitored based on performance on neuropsychological testing and symptom scores. After the rest period, there was significant improvement in neuropsychological test scores and symptom scores with no effect of time elapsed since the concussion.7 Although this study was retrospective, was not randomized, and lacked a control group, it adds credence to the accepted opinion that rest is an effective treatment. Brown et al studied the effect that cognitive activity had on duration of postconcussive symptoms.12 In this prospective cohort study, 335 patients were evaluated within 3 weeks of injury. Using a scale to measure cognitive activity, patients reported their cognitive activity level at each visit; the average activity level was then multiplied by the days between visits to obtain cognitive activity-days. Based on the reported number of cognitive activity-days, the participants were divided into quartiles. The investigators found that those patients in the highest quartile of cognitive activity-days took statistically longer to recover than those in the first to third quartiles of cognitive activity days.12 With the exception of the first study, the evidence indicates that rest is an effective treatment for concussion, even in patients with prolonged symptoms. However, further study is clearly necessary. Current recommendations call for absolute cognitive and physical rest. However, more specific prescriptions for type of rest and intensity of allowable activity may prove to be beneficial. The studies by Majerske et al11 and Brown et al12 suggest that recommending abso-
lute rest from all cognitive and physical activities may prolong recovery compared with allowing some level of cognitive activity. There is little evidence of any other effective treatment for the acute phase of concussion. As concussion symptoms progress without improvement, the patient may progress to the postconcussion syndrome. The treatment of this condition, including vestibular therapy, cervical therapy, and pharmacological therapy, is beyond the scope of this article and is discussed in another article in this issue.13
RETURN TO ACTIVITY Immediate Return to School/Work Return to school or work following treatment for a concussion may prove to be difficult. As concussion may involve cognitive impairment, the increased workload of school or work may worsen symptoms and/or lead to poor performance.14 Although no specific criteria are published for return to work, there is literature regarding return to school for a patient who suffers a concussion.14,15 In the school setting, a coordinated effort must be made between the health care providers, the student, the parents, the teachers, and often the school nurse and guidance counselor to ensure that the student has the necessary accommodations to transition back to school successfully. These accommodations, which could be modified to apply to the work setting, include excused absences from class, rest periods during the day, extension of assignments, postponement of tests, extended testing time, accommodation for light and/or noise oversensitivity, and avoidance of physical exertion.15 Implementation of an individualized education plan or 504 plan for educational accommodations may be necessary.14
Return to Play For athletes who return to sports following a concussion, rapid integration back into sports may worsen symptoms and prolong recovery. Ideally under the guidance of an athletic trainer, the athlete’s physical activity and exertion are increased in a stepwise progression. Once an athlete is asymptomatic at rest (it is the author’s
157
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
MEDICAL TREATMENT OF CONCUSSION/WRIGHT
SEMINARS IN SPEECH AND LANGUAGE/VOLUME 35, NUMBER 3
preference that the athlete has returned to school without symptoms, as well), he or she may start light physical exertion. If asymptomatic during that trial, the exertion is increased 24 hours later. Exertion and sport participation is incrementally increased each day until the athlete can fully participate without symptoms. This progression usually takes 1 week. If at any point during the progression the athlete becomes symptomatic, the athlete must rest 24 hours, and then complete the last step of the progression that he or she was able to complete without symptoms.2
CONCLUSION Though the alternative name for a concussion, mild traumatic brain injury, may imply that this injury is not serious, the consequences of improperly treated concussion can be life altering. Proper recognition and timely, appropriate treatment of a concussion can help to ensure that morbidity is decreased and patients return to their prior functioning without consequence. REFERENCES 1. Rosenthal JA, Foraker RE, Collins CL, Comstock RD. National high school athlete concussion rates from 2005–2006 to 2011–2012. Am J Sports Med 2014;42(7):1710–1715 2. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47(5):250–258 3. Scorza KA, Raleigh MF, O’Connor FG. Current concepts in concussion: evaluation and management. Am Fam Physician 2012;85(2):123–132
2014
4. Putukian M. The acute symptoms of sport-related concussion: diagnosis and on-field management. Clin Sports Med 2011;30(1):49–61, viii 5. Barkhoudarian G, Hovda DA, Giza CC. The molecular pathophysiology of concussive brain injury. Clin Sports Med 2011;30(1):33–48, vii–iii 6. Moser RS, Schatz P. A case for mental and physical rest in youth sports concussion: it’s never too late. Front Neurol 2012;3:171 7. Moser RS, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. J Pediatr 2012;161(5):922–926 8. Griesbach GS, Hovda DA, Molteni R, Wu A, Gomez-Pinilla F. Voluntary exercise following traumatic brain injury: brain-derived neurotrophic factor upregulation and recovery of function. Neuroscience 2004;125(1):129–139 9. Lovell MR, Pardini JE, Welling J, et al. Functional brain abnormalities are related to clinical recovery and time to return-to-play in athletes. Neurosurgery 2007;61(2):352–359, discussion 359–360 10. Gibson S, Nigrovic LE, O’Brien M, Meehan WP III. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj 2013;27(7–8):839–842 11. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train 2008;43(3):265–274 12. Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collins MW, Meehan WP III. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics 2014;133(2):e299–e304 13. Diaz D. Management of athletes with postconcussion syndrome. Semin Speech Lang 2014;35(3): 204–210 14. Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K; Council on Sports Medicine and Fitness Council on School Health. Returning to learning following a concussion. Pediatrics 2013; 132(5):948–957 15. McGrath N. Supporting the student-athlete’s return to the classroom after a sport-related concussion. J Athl Train 2010;45(5):492–498
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
158
Copyright of Seminars in Speech & Language is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
ABSTRACT
A concussion is a brain injury, a change in function induced by traumatic forces. The incidence of concussion is increasing, likely due to increased awareness and improvement in recognition. Speech and language pathology professionals working in schools may encounter patients who have suffered concussions. At the root of concussion pathophysiology is altered metabolism and an acquired energy deficit. The mainstay of treatment for concussion is cognitive and physical rest, allowing for normalization of the metabolism and correction of the energy deficit. Once recovered, the student may need accommodations to successfully return to school without added difficulty and should follow a return to play protocol to return to athletics safely. KEYWORDS: Concussion, rest, return to learn, return to play
Learning Outcomes: As a result of this activity, the reader will be able to (1) describe the symptoms of a concussion; (2) describe the mainstay of acute treatment of a concussion; (3) discuss the evidence regarding physical and cognitive rest as treatment for a concussion; (4) describe the steps involved in the return to school for a patient with concussion; (5) describe the steps involved in the return to sports for an athlete with concussion.
T
he incidence of concussion is increasing, likely due to increased awareness and improved recognition of the symptoms.1 As the rate of concussion diagnoses increases, speech and language pathology professionals who work with schools and athletes will likely encounter more patients who have suffered a concussion. Understanding the underlying pathophysiology and appropriate treatment of concussion will
help to hasten recovery and reduce the risk of postconcussion complications. This article will summarize the current evidence available for the acute treatment of concussion. A concussion is a brain injury caused by a direct blow to the head, face, neck, or elsewhere on the body that transmits the force to the head.2 The diagnosis of concussion is a clinical one, relying on a constellation of signs and
1
Concussion 101 for SLPs; Guest Editor, Anthony P. Salvatore, Ph.D., CCC-SLP Semin Speech Lang 2014;35:155–158. Copyright # 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 5844662. DOI: http://dx.doi.org/10.1055/s-0034-1384676. ISSN 0734-0478.
Department of Family and Community Medicine, Paul L. Foster School of Medicine, El Paso, Texas. Address for correspondence: Justin M. Wright, M.D., CAQ-Sports Medicine, Department of Family and Community Medicine, Paul L. Foster School of Medicine, 9849 Kenworthy St, El Paso, TX 79924 (e-mail: Justin. [email protected]).
155
SEMINARS IN SPEECH AND LANGUAGE/VOLUME 35, NUMBER 3
symptoms that are present following a history of trauma. Headache is the most common presenting symptom.3 Other common symptoms include dizziness, balance disturbance, disorientation, photophobia, phonophobia, amnesia, and nausea. Many patients also report temperament changes and/or emotional lability or may complain of a feeling of fogginess and an inability to focus or concentrate.3,4 The object of the physical exam is to exclude more serious injury, such as a cervical spine injury, skull fracture, or intracranial bleed, but findings in a patient with a concussion may include postural instability and cognitive dysfunction (slow responses, inability to remember a series of numbers or to count backward by sevens). The use of neuropsychological testing has been shown to be of clinical value in the evaluation of concussion and is designed to identify subtle cognitive deficits.2,3 Concussion results from a neurometabolic cascade initiated by an impact to the head, face, or body that transmits the force to the head. This impact leads to the release of excitatory neurotransmitters, disruption of cellular membranes, and ionic flux. To correct the ionic imbalance, large amounts of adenosine triphosphate are required, leading to increased consumption of glucose. At the same time, cerebral blood flow is reduced, eventually leading to an energy mismatch and glucose hypometabolism. Trauma-induced calcium influx leads to mitochondrial dysfunction, further worsening glucose utilization. This process of impaired glucose metabolism and mitochondrial function may take up to 5 to 10 days to normalize.5 Recovery from a concussion requires restoration of the energy balance and normalization of the glucose metabolism. This article will discuss the treatments available to improve symptoms and to shorten recovery time from a concussion.
TREATMENT The mainstay of concussion treatment is physical and cognitive rest in the acute period.2 This period of rest includes time off from school; no homework, reading, visually stimulating activities (computers, video games, texting, use of cell phones, and limited or no TV), exercise, athletics, chores that result in perspiration/exer-
2014
tion, trips, or social visits in or out of the home; and increased rest and sleep.6,7 However, this recommendation was initially based on expert opinion, as prior evidence evaluating the effect of rest on concussion was sparse. Exercise and cognitive activity are thought to increase metabolic activity in the brain, which would further worsen the energy mismatch, worsen symptoms, and further delay recovery. Rat models have demonstrated worsened cognitive performance and delayed recovery with early voluntary exercise following a concussive injury.8 A study using functional magnetic resonance imaging in athletes with concussion demonstrated that those who had the most hyperactivation after injury had longer clinical recovery times than those who did not have hyperactivation.9 Several recent studies have examined the effect of rest on concussion recovery. In a retrospective cohort study of 184 athletes who sustained a concussion, the investigators compared those patients who had the recommendation for cognitive rest documented in the chart with those who did not have such a recommendation documented. They found no difference in duration in concussion symptoms between the two groups.10 However, this retrospective study looked only at documented recommendations and did not determine whether the patients actually followed recommendations. Other studies have shown a more favorable response to rest but still have limitations. In a retrospective cohort study by Majerske et al of 95 student athletes who suffered a concussion, each athlete was stratified to one of five activity levels, based on a self-reported postinjury activity intensity scale.11 Progress was followed using computer-based neurocognitive testing and postconcussion symptom score reporting. Those engaged in the highest amount of activity (school activity and participation in a sports game) scored worse on their neurocognitive testing and reported more symptoms than those in the moderate activity group (school activity and light activity at home). Notably, those in the moderate activity group also performed better and reported fewer symptoms than those in the low activity group (no school or exercise activity). The authors point out that initial activity level may be indicative of the severity of the initial injury, with those who suffered
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
156
more severe injuries limiting their activity spontaneously and those with less severe initial concussions continuing their preinjury level of activity, ultimately leading to worsening neurocognitive and symptom scores.11 In another study, 49 high school and collegiate athletes, with time of presentation ranging from 1 day to several months postconcussion, were prescribed 1 week of cognitive and physical rest at the time of their first postconcussion evaluation. At the second postconcussion evaluation, the decision was made either to continue with rest or to transition to school, based on the patient’s current level of symptoms. Twenty-eight of the 49 patients received an additional week of prescribed rest. Progress was monitored based on performance on neuropsychological testing and symptom scores. After the rest period, there was significant improvement in neuropsychological test scores and symptom scores with no effect of time elapsed since the concussion.7 Although this study was retrospective, was not randomized, and lacked a control group, it adds credence to the accepted opinion that rest is an effective treatment. Brown et al studied the effect that cognitive activity had on duration of postconcussive symptoms.12 In this prospective cohort study, 335 patients were evaluated within 3 weeks of injury. Using a scale to measure cognitive activity, patients reported their cognitive activity level at each visit; the average activity level was then multiplied by the days between visits to obtain cognitive activity-days. Based on the reported number of cognitive activity-days, the participants were divided into quartiles. The investigators found that those patients in the highest quartile of cognitive activity-days took statistically longer to recover than those in the first to third quartiles of cognitive activity days.12 With the exception of the first study, the evidence indicates that rest is an effective treatment for concussion, even in patients with prolonged symptoms. However, further study is clearly necessary. Current recommendations call for absolute cognitive and physical rest. However, more specific prescriptions for type of rest and intensity of allowable activity may prove to be beneficial. The studies by Majerske et al11 and Brown et al12 suggest that recommending abso-
lute rest from all cognitive and physical activities may prolong recovery compared with allowing some level of cognitive activity. There is little evidence of any other effective treatment for the acute phase of concussion. As concussion symptoms progress without improvement, the patient may progress to the postconcussion syndrome. The treatment of this condition, including vestibular therapy, cervical therapy, and pharmacological therapy, is beyond the scope of this article and is discussed in another article in this issue.13
RETURN TO ACTIVITY Immediate Return to School/Work Return to school or work following treatment for a concussion may prove to be difficult. As concussion may involve cognitive impairment, the increased workload of school or work may worsen symptoms and/or lead to poor performance.14 Although no specific criteria are published for return to work, there is literature regarding return to school for a patient who suffers a concussion.14,15 In the school setting, a coordinated effort must be made between the health care providers, the student, the parents, the teachers, and often the school nurse and guidance counselor to ensure that the student has the necessary accommodations to transition back to school successfully. These accommodations, which could be modified to apply to the work setting, include excused absences from class, rest periods during the day, extension of assignments, postponement of tests, extended testing time, accommodation for light and/or noise oversensitivity, and avoidance of physical exertion.15 Implementation of an individualized education plan or 504 plan for educational accommodations may be necessary.14
Return to Play For athletes who return to sports following a concussion, rapid integration back into sports may worsen symptoms and prolong recovery. Ideally under the guidance of an athletic trainer, the athlete’s physical activity and exertion are increased in a stepwise progression. Once an athlete is asymptomatic at rest (it is the author’s
157
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
MEDICAL TREATMENT OF CONCUSSION/WRIGHT
SEMINARS IN SPEECH AND LANGUAGE/VOLUME 35, NUMBER 3
preference that the athlete has returned to school without symptoms, as well), he or she may start light physical exertion. If asymptomatic during that trial, the exertion is increased 24 hours later. Exertion and sport participation is incrementally increased each day until the athlete can fully participate without symptoms. This progression usually takes 1 week. If at any point during the progression the athlete becomes symptomatic, the athlete must rest 24 hours, and then complete the last step of the progression that he or she was able to complete without symptoms.2
CONCLUSION Though the alternative name for a concussion, mild traumatic brain injury, may imply that this injury is not serious, the consequences of improperly treated concussion can be life altering. Proper recognition and timely, appropriate treatment of a concussion can help to ensure that morbidity is decreased and patients return to their prior functioning without consequence. REFERENCES 1. Rosenthal JA, Foraker RE, Collins CL, Comstock RD. National high school athlete concussion rates from 2005–2006 to 2011–2012. Am J Sports Med 2014;42(7):1710–1715 2. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47(5):250–258 3. Scorza KA, Raleigh MF, O’Connor FG. Current concepts in concussion: evaluation and management. Am Fam Physician 2012;85(2):123–132
2014
4. Putukian M. The acute symptoms of sport-related concussion: diagnosis and on-field management. Clin Sports Med 2011;30(1):49–61, viii 5. Barkhoudarian G, Hovda DA, Giza CC. The molecular pathophysiology of concussive brain injury. Clin Sports Med 2011;30(1):33–48, vii–iii 6. Moser RS, Schatz P. A case for mental and physical rest in youth sports concussion: it’s never too late. Front Neurol 2012;3:171 7. Moser RS, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. J Pediatr 2012;161(5):922–926 8. Griesbach GS, Hovda DA, Molteni R, Wu A, Gomez-Pinilla F. Voluntary exercise following traumatic brain injury: brain-derived neurotrophic factor upregulation and recovery of function. Neuroscience 2004;125(1):129–139 9. Lovell MR, Pardini JE, Welling J, et al. Functional brain abnormalities are related to clinical recovery and time to return-to-play in athletes. Neurosurgery 2007;61(2):352–359, discussion 359–360 10. Gibson S, Nigrovic LE, O’Brien M, Meehan WP III. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj 2013;27(7–8):839–842 11. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train 2008;43(3):265–274 12. Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collins MW, Meehan WP III. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics 2014;133(2):e299–e304 13. Diaz D. Management of athletes with postconcussion syndrome. Semin Speech Lang 2014;35(3): 204–210 14. Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K; Council on Sports Medicine and Fitness Council on School Health. Returning to learning following a concussion. Pediatrics 2013; 132(5):948–957 15. McGrath N. Supporting the student-athlete’s return to the classroom after a sport-related concussion. J Athl Train 2010;45(5):492–498
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
158
Copyright of Seminars in Speech & Language is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
