Clinician-to-Clinician Update Clinician-to-Clinician Update

Prolonged Recovery Period after First Concussion in a Young Athlete

June 2016

Contributed by Margaret Semrud-Clikeman, PhD, LP

The median time to resolution of symptoms for adolescents who sustain sports-related concussions is approximately 2 to 3 weeks.1, 2 However, a minority of patients may take much longer to recover.2 Here we report the case of an academically successful, young high school student who sustained a concussion during sports practice and required approximately 7 months to fully recover. During her recovery, she experienced emotional lability, headaches, and difficulties in performing tasks that required sustained attention.

Patient

A 14-year-old girl was referred to University of Minnesota Masonic Children’s Hospital neurology specialists by a local sports-medicine physician for evaluation of persistent neurological symptoms after concussion. She had been diagnosed with a concussion 6 weeks earlier after being hit in the head during sports practice. At the time of the injury, she experienced loss of consciousness for approximately 10 minutes. When she returned to consciousness, she complained of dizziness and headache. The emergency department physician prescribed 2 weeks of rest in a dark and quiet area of the house and avoidance of electronic devices with screens. After 2 weeks, the patient returned to school but had extreme difficulty in concentrating in class. She complained of severe headaches and feeling “foggy.” Her performance at school declined dramatically. When these symptoms did not ease by 6-weeks postconcussion, she was referred to the Pediatric Neuropsychology Clinic. Upon presentation, she was extremely emotionally labile and expressed distress about her poor performance at school, her continued headaches, and problems concentrating.

Management

University of Minnesota Health physicians conducted a full neuropsychological evaluation, which revealed an IQ in the superior range, processing speed in the below average range, and working memory in the below average range. The patient scored unexpectedly low on tests of attention, impulsivity, and executive function, given that she had no history of attention problems and had an exceptional academic record.

We recommended a short amount of low-intensity exercise on the treadmill daily and advised that she attend school for only half the day. With the school, we worked out a plan for the patient to have a note taker during class and to have extended time for tests. We also referred the patient to a cognitive-behavioral therapist to help her cope with the stress of recovery. After 2 weeks, it was evident that the patient could not tolerate even half-days of school without recurrence of her symptoms. Her mother chose to homeschool her until she recovered. After an additional 5 months, the patient’s headaches abated, and her attention span, impulsivity, and executive-function skills returned to levels approaching those seen pre-injury.

June-2016-Peds-Consult-Case-Study-Image-Option-2
— Findings from study of 1,953 adolescents. Heyer GL, et al. Specific factors influence postconcussion symptom duration among youth referred to a sports concussion clinic. J Pediatr. 2016 Apr 4.

Discussion

Recovery periods after concussion can last longer than 2 to 3 weeks. In one study of 1,953 adolescents with concussion, 72.6% had recovered by day 30 postconcussion, 91.4% had recovered by day 60, and 96.8% had recovered by 90 days postconcussion.2 Among athletes competing in comparable sports, female athletes appear to be at a greater risk of concussions than are male athletes.3 Females are also more likely to experience cognitive impairment after concussion than are males.4 Ample time for recovery must be allowed for young patients. Educating patients and parents on concussions is important to achieving optimal support during recovery, and the emotional and behavioral, as well as the physical, aspects of recovery should be assessed. A successful return to school generally requires a re-entry plan and support from the neuropsychologist and medical team along with the aid of school counselors and staff.5


References

  1. Eisenberg MA, et al. Time interval between concussions and symptom duration. Pediatrics. 2013;132:8-17.
  2. Heyer GL, et al. Specific factors influence postconcussion symptom duration among youth referred to a sports concussion clinic. J Pediatr. 2016 Apr 4.
  3. Dick RW. Is there a gender difference in concussion incidence and outcomes? Br J Sports Med. 2009;43 1:i46-i50.
  4. Broshek DK, et al. Sex differences in outcome following sports-related concussion. J Neurosurg. 2005;102:856-863.
  5. Semrud-Clikeman M, Klipfel K M. TBI and concussions in student athletes: How do severity of injury, age, and gender influence recovery. J Pediatr Neuropsychol. 2016;2(1):58-69. DOI 10.1007/s40817-015-0010-8.
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