A new course for concussions

Pediatrician Cheryl Hausman , a "concussion champion" at Children's Hospital, examines Jordan Goins, 12, while his little sister, Jade Dixon, 9, watches. Jordan, after a period of "cognitive rest," was pronounced "perfectly normal." CLEM MURRAY / Staff
Pediatrician Cheryl Hausman , a "concussion champion" at Children's Hospital, examines Jordan Goins, 12, while his little sister, Jade Dixon, 9, watches. Jordan, after a period of "cognitive rest," was pronounced "perfectly normal." CLEM MURRAY / Staff
Posted: October 10, 2012

A couple of years ago, when Jasir Huff, now 6, suffered a concussion, all his mother was told to do was give him some ibuprofen and keep an eye on him.

When Jasir's big brother, Jordan Goins, 12, fell and struck his head on the concrete basketball court at his school in September, it was a whole new ball game. Jordan's pediatrician, who is part of Children's Hospital of Philadelphia's primary care network, ordered "cognitive rest" for his concussion.

That meant no school, no homework, no computer, no texting, and no video games.

This all came as a surprise to his mother, Nicole Dixon, and not a welcome one. But she was worried. Her son was having headaches, balance problems, fatigue, and sensitivity to light. He was spelling words wrong. She clamped down.

"It was hard. Very hard," she told the pediatrician, Cheryl Hausman, during a follow-up visit at her Roxborough office last week. "He was bored."

He also got a lot better. Hausman, who last spring became one of Children's primary care "concussion champions," pronounced Jordan "perfectly normal." She said he could ease back into school with half-days and then, when they were sure his symptoms were gone, start becoming more physically active again.

Children's is endorsing this new approach to concussion - not just staying off the playing field but also avoiding most of the things that occupy the brains of modern children - for the 31 primary care offices in its network.

"It's probably the quickest way for them to get back to 100 percent school and play," said Christina Master, a Children's pediatrician and associate program director of the primary care sports medicine fellowship. She helped develop the protocol that Hausman uses.

School is the work of children, Master argues, and thinking - not returning to play - should be the focus of their concussion recovery.

Publicity in recent years about emotional, cognitive, and memory problems in aging football and hockey players who suffered multiple concussions during their careers has raised the anxiety level around the topic. A lawsuit by thousands of NFL players who claim the league did not keep them well enough informed about the long-term risks of concussion - dementia is one of them - is based in Philadelphia and has raised even higher the profile of what doctors call mild traumatic brain injury.

The idea that kids need "cognitive rest" after a concussion has been gaining traction in the last two to four years, experts said. In an article in the journal Pediatrics in 2010, the Council on Sports Medicine and Fitness called cognitive and physical rest the "mainstay of management." The consensus statement of the 2008 International Symposium on Concussion in Sport in Zurich also supported the idea.

Still, some doctors remain skeptical that there is enough scientific evidence to justify such an extreme response. Mark DiFazio, a neurologist at Children's National Medical Center in Washington, says there is no proof that trying to stop kids from straining their brains is better than letting them behave more normally. Plus, there's no way to stop thinking.

"If I tell you to stop thinking and rest, what does that do to your brain? Does that put you into a meditative state?" he asked. "Absolutely not."

He said research does show that kids feel better if doctors reassure them that most people recover just fine.

Master concedes that the new approach is based mostly on clinical observation and research in young rodents. There is evidence that blood flow to the brain after a concussion slows more in kids than in adults. The brain needs the energy that blood delivers for healing, Master said. Animal studies have shown that making mice navigate a maze after a concussion slowed their recovery.

Rosemarie Moser, a neuropsychologist who directs the Sports Concussion Center of New Jersey, recommends cognitive rest for her patients. She recently conducted a retrospective study that found that patients' symptoms improved significantly after rest even a month or more after the injury, but it did not include a control group. "By clinical consensus of experts, rest makes sense," she said.

Gerald Gioia, division chief for pediatric neuropsychology at Children's National - the same hospital as DiFazio - thinks the best argument for cognitive rest is that it seems to work. Concussion is a serious injury, not the brain equivalent of a sniffle.

Doctors don't know, he said, whether doing hard mental work such as AP calculus makes recovery take longer or makes it less complete. "What we do know is that it makes kids feel lousy."

DiFazio says kids should take a break if an activity brings on symptoms, but he says there's no evidence that pain or other symptoms mean they're exacerbating the injury. "It doesn't mean that you're further injuring the brain," he said.

Doctors define cognitive rest differently. Gioia says the treatment needs to be individualized and "reasonable." He prefers to talk about "managed cognitive activity" that takes into account how long kids can focus without feeling bad.

Taking a serious rest at first is a good idea, he said. Many kids are very tired in the first days after a concussion and want to rest. All the hubbub of school, plus carrying around a 30-pound backpack, can be too much. "The first few days can be really rough on the kids," he said.

One goal is to make sure that kids stay away from contact sports until they are thinking and moving quickly enough to avoid getting another concussion right away. Multiple concussions have forced some of Master's patients to "retire" from their sport at 12 or 13.

Master, the mother of two ice hockey players, knows that enforcing cognitive rest can be a challenge. Without computers, video games, cellphones, and sometimes even television, what is there?

"Baking seems to be universally tolerated," she said. Some kids will report that "folding laundry mindlessly" is no problem, but "if I look for a sock, I get a headache."

It turns out the "grandparent pace of life" is about right, she said. "Grandparents are great for concussions."


Contact Stacey Burling at 215-854-4944 or sburling@phillynews.com.

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