美国儿科学会：脑震荡学生或需停课休息

脑震荡患者需要医生提供有关返校上课方面的指导，以确保促进而不是阻碍其恢复。为此，美国儿科学会(AAP)发布了一份临床报告以帮助这类患者。

AAP运动医学与健身理事会和AAP学校卫生理事会的Mark E. Halstead博士及其同事报告称，关于儿童脑震荡的研究大多关注患儿运动或其他身体活动的恢复，而有关“恢复学习”的管理资料却很少。许多已发表的声明都强调了“认知休息”的必要性，即避免明显的潜在认知压力源，比如课堂练习和家庭作业，但却没有指出并解决其他可能阻碍恢复甚至加重症状的各种刺激因素(Pediatrics 2013;132:948-57)。



据估计，每年大约会发生170万例外伤性脑损伤，其中许多都属于脑震荡。“由于学生通常在脑震荡后看起来身体情况不错，因此教师、学校管理者和同学可能很难完全理解一名脑震荡患儿可能出现的缺陷程度。”这样一来，校方可能就不愿接受他们必须为这类学生做出课程调整的建议。

美国圣路易斯华盛顿大学/圣路易斯儿童医院的骨科医生/运动医学专家Halstead博士及其同事指出，最好是由儿科医生来告知教师和患儿本人及其家属可能出现的症状以及恢复过程中如何预防或尽量避免认知压力的策略。Halstead博士还在10月27日于奥兰多召开的AAP 2013年会上公布了这份临床报告。

这份临床报告指出，大部分脑震荡患者会在受伤后3周内恢复，因此学校环境所需的调整大多都可以在个别教室中进行，而无需制定正式的书面计划，比如504计划或者个性化教育计划。不过，需要更长时间恢复的学生可能就需要更加正式的调整和安排。

这份报告列举了脑震荡的典型症状和体征，以及老师和管理者可以做出哪些调整来帮助患儿重返学校。

头痛是最常见的症状，在整个恢复期都可能反复发作。校方应该意识到荧光照明、很大的噪音、甚至就是专注一项任务都可能会诱发这类患者出现头痛，因此必要时应该允许他们在安静的区域休息。

眩晕和头晕也很常见，快速起立、在拥挤的人群中穿行、甚至只是注视屏幕上的运动或一个人的运动都可能诱发这类症状。必要时应该允许脑震荡患儿闭上眼睛或者把头埋在课桌上休息，也应该允许他们避开拥挤的走廊，从一个地方缓慢移动到另一个地方。

常见的视觉症状包括光敏感和视物模糊或复视。应该允许学生佩戴有帽沿的帽子或者太阳镜，关闭或调暗室内灯光，调暗视频屏幕，或者放弃电影或幻灯片展示。如果他们阅读或书写有困难，甚至在关注视觉任务时也出现了问题，他们应该得到谅解。

Halstead博士及其同事说，对噪音敏感意味着脑震荡患儿可能需要避开餐厅、休息室、购物课程、音乐(乐队或唱诗班)课程、体育馆活动以及其他噪音很大的地方，也应该允许他们使用耳塞。

脑震荡患儿也可能出现专注力和记忆力方面的问题。应该理解他们可能难以吸收新知识以及在课堂上专心听讲；特别是考试，尤其是标准化考试，可能需要推后直至患儿的脑震荡完全康复。

最后，脑震荡往往会引起睡眠障碍，从而导致过度疲劳、迟到、在课堂上睡着以及经常缺课。患儿可能需要晚到学校或者提前放学以便其充分休息。

这份AAP临床报告还得到了美国运动医学学会、美国脑损伤学会、加拿大儿科学会、美国国家学校护士协会、美国国家学校心理学家协会以及美国国家高中协会全国联合会的联名认可。

除非“在失效时或失效前重新发布、修订或作废”，所有AAP临床报告自发布之日起5年后自动失效。

作者声明无利益冲突。

专家点评：为“恢复学习”提供了全面的指导

鉴于脑震荡后恢复学习(RTL)的问题一直没有得到充分的解决，这份AAP临床报告显得十分必要。校方和老师很少能够理解脑震荡对受伤学生造成的负面影响。这可能导致学生成绩下降，压力很大，这些都可能影响他们的康复。好在目前许多学校和运动机构都制定了相应的计划来帮助受伤的运动员重返赛场，但是学生-运动员其实还能从RTL补充计划中获益。

对于学校而言，RTL并不是一个新的命题，因为许多学校已经针对其他疾病，比如慢性病或学习障碍制定了相应的计划。这份报告就为学校制定其RTL计划提供了框架。

Mark E. Halstead博士及其同事提供的范例是一个已经被许多州成功使用的计划。虽然好的计划都有一些相似之处，但是每所学校应该根据自身的教学需求制定个性化的RTL计划。

尚需开展进一步的研究以验证这一计划并且找出哪些教学调整对于遭遇了脑震荡的学生-运动员最有帮助。

Kevin D. Walter博士是美国威斯康辛医学院的骨科学/儿科学副教授，供职于医学研究院青少年运动相关脑震荡委员会。

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By: MARY ANN MOON, Clinical Neurology News Digital Network

Patients who sustain a concussion need their physicians’ guidance in returning to school in a way that facilitates rather than hinders their recovery, and the American Academy of Pediatrics has issued a clinical report to help.

Most research on pediatric concussions has focused on returning the patient to sports or other physical activities, while data for managing the "return to learn" are sparse. Many published statements emphasize the need for "cognitive rest" – avoiding obvious potential cognitive stressors such as class work and homework – but fall short of identifying and dealing with the myriad other stimuli that can impede recovery or even worsen symptoms, reported Dr. Mark E. Halstead and his associates on the AAP Council on Sports Medicine and Fitness and the AAP Council on School Health (Pediatrics 2013;132:948-57).
 
An estimated 1.7 million traumatic brain injuries occur each year, many of them concussions. "Given that students typically appear well physically after a concussion, it may be difficult for educators, school administrators, and peers to fully understand the extent of deficits experienced by a student with a concussion." This, in turn, might make school officials reluctant to accept that they must make adjustments for such students.

Pediatricians are in an excellent position to inform these educators, as well as the patients themselves and their families, of the symptoms that might develop and the strategies to prevent or minimize cognitive stress during recovery, said Dr. Halstead, an orthopedic surgeon and sports medicine specialist at Washington University in St. Louis and Children’s Hospital of St. Louis, and his associates. Dr. Halstead also presented the clinical report Oct. 27 at the annual meeting of the American Academy of Pediatrics in Orlando.

The clinical report notes that most concussions resolve within 3 weeks of the injury, so most adjustments to the school environment can be made in the individual classroom setting without the need for a formalized written plan such as a 504 plan or individualized education plan. However, students who require longer-term recovery need more formalized accommodations and modifications.

The report lists typical signs and symptoms of concussion, along with adjustments that teachers and administrators can make to help the child returning to school.

Headache is the most frequent symptom and can recur throughout recovery. School personnel should be made aware that fluorescent lighting, loud noises, and even simply concentrating on a task can elicit headache in these patients, so they should be allowed to take breaks in a quiet area when needed.

Dizziness and lightheadedness also are common and can be provoked by standing quickly, walking in a crowd, or even just viewing motion on a screen or in person. Students with concussion should be allowed to close their eyes or put their heads down on the desk if necessary, and should be permitted to avoid crowded hallways and to move slowly from one place to another.

Common visual symptoms include light sensitivity and blurred or double vision. Students should be allowed to wear a hat with a brim or sunglasses, to turn off or dim room lights, to dim video screens, or to forgo movies or slide presentations. They should be excused if they have trouble reading or writing, or even paying attention to visual tasks.

Sensitivity to noise means that students with concussion might need to be excused from the lunchroom, recess, shop classes, music (band or choir) classes, activities in a gymnasium, and any other excessively noisy location, and should be permitted to use earplugs, Dr. Halstead and his associates said.

Students with concussion also have trouble with concentrating and remembering. Allowances should be made for a student’s difficulty absorbing new material and focusing in the classroom; in particular, testing, especially standardized testing, might need to be postponed until after the student has recovered from the concussion.

Finally, concussions often cause sleep disturbances that can lead to excessive fatigue, tardiness, falling asleep in class, and excessive absences from class. Students might require a late start to the school day or a shortened school day to allow them to rest.

This AAP clinical report was endorsed by the American Medical Society for Sports Medicine, the Brain Injury Association of America, the Canadian Paediatric Society, the National Association of School Nurses, the National Association of School Psychologists, and the National Federation of State High School Associations.

All clinical reports from the AAP expire automatically 5 years after publication unless "reaffirmed, revised, or retired at or before that time."

No conflicts of interest were reported.

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A comprehensive foundation for return to learning

This clinical report for the AAP is greatly needed, as the topic of return to learning (RTL) after concussion has been inadequately addressed. It is rare for school personnel and teachers to understand how concussion negatively impacts the injured student. This can cause a potential drop in grades and significant stress, which may delay recovery. Thankfully, many schools and athletic organizations have created plans to help injured athletes return to play, but now student-athletes will benefit from a complementary plan dedicated to returning to academics.

RTL is not a new topic for schools, as many have created plans for other conditions such as chronic illnesses or learning disorders. This report provides a framework that schools can use to create their own RTL plan.

The example put forth by Dr. Mark E. Halstead and his colleagues is a program that has been used successfully in several states. While the components of any good plan are similar, each school may tailor an RTL program to its unique academic needs.

Further research is still needed in order to help validate this program and to identify which academic adjustments are most beneficial to the concussed student-athlete.

Dr. Kevin D. Walter is associate professor of orthopedic surgery and pediatrics at the Medical College of Wisconsin in Milwaukee, and serves on the Institute of Medicine’s Committee on Sports-Related Concussions in Youth.