Concussion Management in the School Setting

1. Concussion Management in the School Setting John Reynolds MS, ATC, VATL FCPS Athletic Training Program Administrator

2. Key Concepts • Our collective understanding about concussions has evolved in a short period of time • Fastest growing public health initiative in US history • Effective concussion treatment depends on providing quality rest • Academic impact on student • Return-to-learn and return-to-play progressions are critical elements of the recovery process • Supporting students throughout

3. What is a Concussion? “…complex pathophysiological process affecting the brain, induced by traumatic biochemical forces.” (Zurich 4th Consensus Statement on Concussion in Sport, 2013) Concussion IS NOT a hardware problem… i.e. caused by structural changes in the brain • Concussion ISA software problem… • i.e. a product of chemical changes in the brain Routine diagnostic imaging (CT scans, MRIs, x-rays) will likely be normal

4. The TBI Continuum Mild Moderate Severe } } } Traumatic Brain Injury { Concussion

5. A New Understanding • Approximately 4 million sports-related concussions occur each year • Only about 10% of concussions are associated with loss of consciousness (LOC) • No more grading scales • Over 20 different scales have been implemented • Can’t predict severity on symptoms alone • Must wait to see how long recovery takes to determine how “bad” it was

6. What’s Involved in Concussion Management? { Communication Communication is critical!

7. The Law and BOE Guidelines: 2010 • Local school districts required to develop concussion policies that include: • Annual concussion education for parents and students • Removal of student from play if concussion suspected • No return to play (RTP) that day nor until evaluated and cleared by appropriate licensed health care provider • ATC, MD, DO, NP, PA, Neuropsychologist • A graduated RTP progression • The Ultimate Goal: to promote awareness and keep kids safe!

8. The Law and BOE Guidelines: 2014 • HB 190/410 • Concussion education to include effect on academic performance • Youth sport organizations required to develop policies consistent with local school/VBOE Guidelines • HB 1096 • VBOE Guidelines amended to include return-to-learn protocol • School personnel alert to cognitive/academic concerns • Students gradually return to full academic activities

9. The Law and BOE Guidelines • Are you familiar with your school’s policies? • How does your school division provide parent/student concussion education? • Who supervises the return-to-learn and return-to- play progressions? • While this only applies to student-athletes, concussions can happen to all students • What happens in middle schools? • What happens in elementary schools?

10. What does the Future Hold? ??? • What are the long-term consequences? • How many is too many? • Can we make sports safer?

11. The Pendulum is Swinging… Just Right Minimal Overkill

12. How do you Identify a Concussion? Physical • Headache • Nausea/vomiting • Dizziness • Balance problems • Vision/hearing problems • Fatigue • Sensitivity to light/noise Cognitive • Confusion • Feeling “foggy” • Feeling slowed down • Difficulty concentrating • Difficulty reading/writing • Difficulty problem solving • Memory loss Emotional • More emotional • Irritable • Apathetic • Impulsive • Anger/easily frustrated • Nervousness • Depression/anxiety Sleep • Drowsiness • Sleeps too much • Sleeping too little • Trouble falling asleep

13. What Does Concussion “Look” Like? • No two concussions “look” the same, even in the same person • These variations create challenges when trying to identify and manage concussion • Hard to predict how a given person will be affected • As a result, must take the necessary steps to manage concussion appropriately at earliest opportunity

14. When to Rush to the Hospital These are signs of a MEDICAL EMERGENCY! • Headaches that worsen • Repeated vomiting • Seizures • Neck pain • Very drowsy • Significant irritability • Unusual behavior changes • Slurred speech • Weakness/numbness in arms/legs If symptoms get worse following the injury CALL 911 or GO TO THE HOSPITAL

15. Keys to Concussion Treatment • Physical and Cognitive rest • Minimizing physical and mental activities essential to brain recovery • Avoid further trauma/injury to the brain • Sleep is essential • No need to awaken during the night Don’t do anything that makes symptoms worse!

16. What is Physical Rest? • Avoiding activities that elevate heart rate or expose the student to contact • Applies to activities both inside and outside of school • Sport practices or competitions (school and non-school) • Limited participation in PE, Music, Drama, Dance • Cross training, walking the dog • Household chores

17. What is Cognitive Rest? • Limiting activities that require concentration • Homework, schoolwork or job-related work • Texting • Phone , computer or television use • Video games • May require changes to normal academic day

18. Common Symptom Triggers • Environmental conditions • Light, noise • Physical exertion • Navigating the building • Managing crowded environments • Mental exertion • Concentrating, attending to task • Organization • Multi-step tasks • Demonstrating understanding • Formative and summative assessments • Changing focus of attention • Desk to front of room

19. A New Perspective • Concussion can happen to every student, not just student-athletes • Accidents at home, playground injuries, falling off a bike • Concussion affects a student’s ability to concentrate and focus on tasks • May have great difficulty comprehending or demonstrating understanding • Recognize that school personnel have a vital role in managing concussion • Teachers, counselors, administrators, etc. • Facilitating cognitive rest • Significant impact of student recovery • Effective implementation leads to better outcomes

20. Steps Schools Can Take • Identify your resources • School nurse, athletic trainer, team physician, coach, etc. • Utilize your resources to develop/revise your concussion policy • Facilitate communication between all parties early and often until student recovers • Parents/athletic trainer/counselors/school nurse, coach, etc.

21. Student Parent/ Guardian Teacher School Counselor Concussion specialist Treating Physician School Admin Coach School Nurse Athletic Trainer Team Physician

22. Cognitive Rest: Important Considerations 1. Students may have difficulty learning at the same rate as before the injury and demonstrating what he/she knows • Emphasize learning essential knowledge and concepts • Limited/no classroom or standardized testing • Work on comprehension of smaller amounts of material • Reduced homework/coursework and/or extra time • Break larger tasks into smaller parts 2. Students may experience a wide range of emotions following a concussion • Minimize unnecessary stress or anxiety related to completing assignments and assessments • Develop schedule for completing critical assignments • Avoid applying undo pressure related to returning to normal academic activities or activity/sport participation • Anxiety may exacerbate/prolong existing symptoms

23. Cognitive Rest: Important Considerations 3. Students may have difficulty performing common activities that rely on precise eye movements • Reduce activities that necessitate repeated eye movement (reading) or changing focus of attention (back and forth between front of room and desk) • Consider incorporating different presentation styles (less reading or watching, more listening) 4. Students may experience an intensifying of symptoms following physical exertion • Encourage rest, limited physical activity

24. Cognitive Rest: Important Considerations 5. Students may have difficulty maintaining normal sleep/rest patterns and habits • Encourage/facilitate rest opportunities during the normal academic day 6. Students may have difficulty functioning in the academic environment • Leave early from class to navigate uncrowded hallways • Avoid cafeteria, gyms or other noisy environments • Wear sunglasses, move away from widows or other sources of light

25. Cognitive Rest: Important Considerations 7. Students may have difficulty managing their school schedule • Shortened classes/shortened school day • Realignment or balancing of schedule, online courses • PE, band, music, theatre, etc. are common problem areas

26. Refining Instructional Strategies

27. Facilitating Cognitive Rest What about 504 plans???

28. Facilitating Cognitive Rest Remember… • Concentrating, remembering, focusing are hard when you have a concussion • Students will have difficulty demonstrating their understanding of material • All of this is usually temporary • In many cases lasting only a few weeks • These strategies WILL be suggested by physicians/ concussion specialists Providing all of this can be a daunting task, but… … it is essential to the successful recovery of the student!

29. What is Return-to-Learn? • Systematic/progressive reintroduction of cognitive/academic activities • School attendance • Amount/type of school work • Level of academic support/instructional strategies • Typically includes series of distinct stages lasting days or weeks, occasionally longer

30. Sample Return to Learn Progression Adapted from “Importance of ‘Return-to-Learn’ in Pediatric and Adolescent Concussion,” Mster, Gioia, et a; Pediatric Annals, 2012

31. Return-to-Learn: Lessons Learned • Individualized nature of this injury most apparent during this process • Nothing about this is “one size fits all” • Frequent re-evaluation helpful • Really need to pay attention to changes in symptoms • Students may not require supports across all classes • Student may benefit from different supports in different classes

32. When is it Safe to Return to Play? • Student no longer exhibits any signs or symptoms consistent with concussion • Student has received written medical release from an appropriate licensed health care provider • Student successfully completes return to play progression • Describes a period of supervised exercise that is gradually intensifying in nature • Process takes a MINIMUM of 5-7 days to complete depending on nature of sport • 24 hours between stages • Must be asymptomatic to progress to next stage

33. Return to Physical Activity • Progressive return to physical activity also necessary in certain academic classes • HPE • Band/orchestra/chorus • Drama

34. Returning to Play: Lessons Learned • Ideally, student participating without support throughout the academic environment BEFORE returning to sports • Effective communication between staff is critical • Regular evaluation during the progression is critical to ensure student remains symptom-free • Who provides this evaluation?

35. Role of the School Nurse • Ultimately depends on school division policy… • Acknowledge that concussion and its impact on students is “real” • Facilitate communication between stakeholders • Parents, medical professionals, teachers, counselors etc. • Advocate for students throughout recovery

36. Resources • ACHIEVES Proactive Concussion Recovery Toolkit • http://concussiontoolkit.gmu.edu/ • Brain Injury Association of Virginia- Sports Concussion • www.biav.net/sports-concussion.htm • Centers for Disease Control • http://www.cdc.gov/concussion/HeadsUp/schools.html • Children’s Nationwide Hospital • http://www.nationwidechildrens.org/concussions • Virginia Athletic Trainers’ Association- What is an Athletic Trainer? • www.vata.us • Virginia High School League Sports Medicine Advisory Committee • www.vhsl.org/sports_medicine

37. References • American Academy of Pediatrics • http://pediatrics.aappublications.org/content/126/3/597.full.pdf+html • Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 • http://bjsm.bmj.com/content/47/5/250.full.pdf+html • Heads Up Concussion from the CDC • Youth Sports: www.cdc.gov/concussion/HeadsUp/youth.html • High School: www.cdc.gov/concussion/headsup/high_school.html • “Importance of ‘Return-to-Learn’ in Pediatric and Adolescent Concussion,” Master, Gioia, et al; Pediatric Annals, 2012 • Virginia Board of Education – concussion guidelines • www.doe.virginia.gov/boe/guidance/health/concussions_in_student_athletes.pdf