Concussions and the Road Back to the Classroom

Gerard A. Gioia, Ph.D.Gerard A. Gioia, Ph.D.Pediatric NeuropsychologistPediatric Neuropsychologist

Chief, Division of Pediatric NeuropsychologyChief, Division of Pediatric NeuropsychologyDirector, Safe Concussion Outcome, Director, Safe Concussion Outcome,

Recovery & Education (SCORE) ProgramRecovery & Education (SCORE) ProgramChildren’s National Medical Center Children’s National Medical Center

Washington, DCWashington, DC

Disclosure Test AuthorTest Author

Behavior Rating Inventory of Executive Function Behavior Rating Inventory of Executive Function (BRIEF) Psychological Assessment Resources, Inc.(BRIEF) Psychological Assessment Resources, Inc.

Tasks of Executive Control (TEC)Tasks of Executive Control (TEC) Pediatric Immediate Post-Concussion Assessment Pediatric Immediate Post-Concussion Assessment

and Cognitive Testing (Pediatric ImPACT)and Cognitive Testing (Pediatric ImPACT) Acute Concussion Evaluation (ACE)Acute Concussion Evaluation (ACE) Concussion Recognition & Response AppConcussion Recognition & Response App Concussion Assessment & Response (CARE) AppConcussion Assessment & Response (CARE) App

Plan for the Day Concussion 101: What is it?Concussion 101: What is it? Effects of Concussion on School Learning & Performance Effects of Concussion on School Learning & Performance Effects of School Learning & Performance on Concussion Effects of School Learning & Performance on Concussion

RecoveryRecovery Strategies for Supporting RecoveryStrategies for Supporting Recovery Q&AQ&A

BreakBreak Small Groups: Examining your concussion policies & Small Groups: Examining your concussion policies &

procedures, developing/ expanding procedures, developing/ expanding Large Group: Discussion of policies & procedures; Q&ALarge Group: Discussion of policies & procedures; Q&A

“Your Brain is Your Future”

(and the source of your parents’ retirement…)(and the source of your parents’ retirement…)

A concussion is a brain injury

Brain injuries threaten the Child’s future

Concussion Care for Kids: It’s a TEAM Sport!

Who’s on the Team?

Child/ Teen(Student, Athlete,

Son/Daughter,Friend)

Family

Medical Systems

Pre-Hospital (EMS) Emergency

Urgent Primary Care

Specialty Care

School

Four Corners Approach to

Concussion Care

Administrators Athletic/ Recreational

AdministratorsCoachesOfficialsParents

Teammates

Teachers

School Nurse/ Counselor

Psychologist

Certified Athletic Trainer

Certified Athletic Trainer

Certified Athletic Trainer

What is a Concussion? A concussion is an A concussion is an injury to the braininjury to the brain

caused by a direct blow to the head, face, caused by a direct blow to the head, face, neck or elsewhere on the body that causes neck or elsewhere on the body that causes the head and brain to move rapidly back the head and brain to move rapidly back and forth. and forth.

A concussion results in the onset of A concussion results in the onset of impaired brain functionimpaired brain function, producing a set of , producing a set of clinical clinical signs and symptomssigns and symptoms (physical, (physical, cognitive, emotional, sleep) that may or cognitive, emotional, sleep) that may or may not involve loss of consciousness. may not involve loss of consciousness.

What is a Concussion? Recovery of the clinical and cognitive Recovery of the clinical and cognitive

symptoms symptoms typicallytypically follows a sequential follows a sequential course over a period of days to weeks.course over a period of days to weeks.

In a small percentage of cases, post-In a small percentage of cases, post-concussive symptoms concussive symptoms may be prolongedmay be prolonged for for months or longer. months or longer.

Typically, no abnormality on standard Typically, no abnormality on standard structural neuroimaging studies (CT, MRI) structural neuroimaging studies (CT, MRI) is seen in a concussion.is seen in a concussion.

Effects of Concussive Forces on the Brain

Typically, the “software” of the brain is Typically, the “software” of the brain is affected affected Neurometabolic/ neurochemical processesNeurometabolic/ neurochemical processes PhysiologicalPhysiological

Not the “hardware” Not the “hardware” Structure Structure

Neurometabolic Cascade FollowingTraumatic Brain Injury

2 6 12 20 30 6 24 3 6 10

minutes hours days

500

400

300

200

0

50

100

% o

f nor

mal K+

Glutamate

Glucose

Cerebral Blood Flow

Calcium

UCLA Brain Injury Research Center

(Giza & Hovda, 2001)

Signs You May See (Acutely)

Recovery From Concussion:How Long Does it Take?

0

10

20

30

40

50

60

70

80

90

100

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+

All Athletes No Previous Concussions 1 or More Previous Concussions

N=134 High School athletes

WEEK 1

WEEK 2

WEEK 3

WEEK 4

WEEK 5

Collins et al., 2006, Neurosurgery

Focus on School Return & Support

"You can't educate a child who isn't healthy, and you can't keep a child

healthy who isn't educated."    Joycelyn Elders

Effect of Concussion on School Learning &

Performance

Effect of School Learning & Performance on Concussion Recovery

SchoolKid’s Major “Job”

NewNew Learning/ Learning/ AcquiringAcquiring Knowledge Knowledge AcademicAcademic SocialSocial

PracticingPracticing incompletely learned knowledge incompletely learned knowledge

Mental/ Cognitive Mental/ Cognitive exertionexertion is essential to is essential to new learning/ practicenew learning/ practice

School professionals should watch for students who show increased

problems Paying attention Problems remembering or learning new information Inappropriate or impulsive behavior during class Greater irritability, less ability to cope with stress Difficulty organizing tasks Fatigue in class Onset of or worsening headaches

Concussion’s Effects on School Learning & Performance 80 students with concussions80 students with concussions

““Which specific types of problems are you Which specific types of problems are you experiencing in school?”experiencing in school?”

Students reported an average of 4 problems below. Students reported an average of 4 problems below. Headaches interfering Headaches interfering 71.3% 71.3% Can’t pay attn in class Can’t pay attn in class 62.5% 62.5% HW taking much longer HW taking much longer 59.5% 59.5% Difficulty studying for test/quiz Difficulty studying for test/quiz 51.9% 51.9% Too tired Too tired 50.6% 50.6% Diffic understanding material Diffic understanding material 44.0% 44.0% Difficulty taking notes Difficulty taking notes 28.8% 28.8%

Concussion’s Effects on School Learning & Performance

““Which classes are you having the most trouble with?”Which classes are you having the most trouble with?”(Percent reporting trouble in class) (Percent reporting trouble in class)

Parent Parent StudentStudent Math Math 60.3% 60.3% 73.7% 73.7% Reading/LA Reading/LA 38.1% 38.1% 46.1% 46.1% Science Science 38.1% 38.1% 47.4% 47.4% Soc Stud Soc Stud 38.1% 38.1% 40.8% 40.8% Foreign Lang Foreign Lang 38.1% 38.1% 38.2% 38.2% Music Music 6.3% 6.3% 17.9% 17.9% PE PE 7.9% 7.9% 10.5% 10.5% Art Art 3.2% 3.2% 5.3% 5.3% -None-None 25.4%25.4% 6.6% 6.6%

Effect of School Learning & Performance on

Concussion Recovery

86.6%83.3%

46.8%

3.0% 3.0% 3.2%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Percent Reporting

Yes No Opportunity

Presence of Symptom Worsening

Cognitive Exertion - 3 Visits

Visit 1 (13 days) Visit 2 (28 days) Visit 3 (45.5 days)

N= 72 Gioia et al., 2010

Cognitive Demands of School Worsen Symptoms

British Journal of Sports Medicine 2009 43 (Suppl I) i76-i84.

Sources of Mental/ Cognitive Activity?

Prolonged concentrationProlonged concentration Prolonged homeworkProlonged homework Prolonged classes (block scheduling)Prolonged classes (block scheduling) Prolonged daysProlonged days Excessive TV, computer, socializing…Excessive TV, computer, socializing…

These sources and degrees of activity are likely to vary from person to person

Keys to Recovery Resting the brain & getting good sleepResting the brain & getting good sleep No additional forces to head/ brainNo additional forces to head/ brain Managing/ facilitating physiological recoveryManaging/ facilitating physiological recovery

Avoid activities that produce symptomsAvoid activities that produce symptoms Not over-exerting body or brainNot over-exerting body or brain

Ways to over-exertWays to over-exert PhysicalPhysical EmotionalEmotional Cognitive! Cognitive! (concentration, learning, memory)(concentration, learning, memory)

Athletic Therapy March, 2010

“Physical rest alone fails to address another key aspect of brain function in youth – mental exertion associated with school activities.”

What is cognitive “rest?”What is cognitive “rest?”

The concept of cognitive exertional activity (and rest) viewed The concept of cognitive exertional activity (and rest) viewed along a along a continuumcontinuum of activity of activity

No activity/full rest No activity/full rest Full activity/no restFull activity/no rest

In reality, In reality, nono cognitive activity/full cognitive rest not cognitive activity/full cognitive rest not practical/likely (unless asleep or comatose)practical/likely (unless asleep or comatose)

Therapeutic goalTherapeutic goal is to is to limitlimit cognitive activity to a level that is cognitive activity to a level that is tolerable, and does not exacerbate or cause the re-tolerable, and does not exacerbate or cause the re-emergence of symptomsemergence of symptoms

Cognitive ManagementCognitive Management

Supporting student recovery requires collaborative approach among school professionals, health care professionals, athletics, parents, and students.

All school staff should be educated/ informed about the returning student’s injury and symptoms

School staff must assist with transition process and making accommodations for student.

Purpose of Care Plan

Guide recovery

Educate

Manage exertional activity, safety

Return to School

Return to Sports

Summary• Concussions can have a significant effect on the Concussions can have a significant effect on the

injured student’s school learning injured student’s school learning • School learning can potentially have a significant School learning can potentially have a significant

effect on recovery from concussioneffect on recovery from concussion• Schools and school personnel play an important Schools and school personnel play an important

role in assisting the student with concussion.role in assisting the student with concussion.• Understanding and monitoring the student’s Understanding and monitoring the student’s

symptoms is critically important symptoms is critically important

• Assisting the symptomatic student by reducing Assisting the symptomatic student by reducing demands – physical and cognitive demands – physical and cognitive

• Gradual increase in academic demands as Gradual increase in academic demands as symptoms reducesymptoms reduce

• Return to sports participation, PE, or any other risk Return to sports participation, PE, or any other risk activity requires clearance from a health care activity requires clearance from a health care professional with training in concussion evaluation professional with training in concussion evaluation and managementand management

SummarySummary

Q & A

Questions for Schools to Ask and Prepare for

1.1. When a student is identified with a concussion, what is your When a student is identified with a concussion, what is your response? High school, middle school, elementary schoolresponse? High school, middle school, elementary school

2.2. What/ who is the team?What/ who is the team?1.1. Who does the parent contact?Who does the parent contact?2.2. Who will connect with the teaching team? Who will connect with the teaching team?

1.1. Method to disseminate student needs with Method to disseminate student needs with accommodations/ strategiesaccommodations/ strategies

3.3. Who will do what?Who will do what?4.4. What will you do?What will you do?5.5. How will you monitor the moving target of recovery, and adapt How will you monitor the moving target of recovery, and adapt

the accommodations as needed (i.e., this is not a black & the accommodations as needed (i.e., this is not a black & white situation)white situation)

6.6. What is program for in-servicing teachers about concussion What is program for in-servicing teachers about concussion and its effects?and its effects?

Support / Accommodations Procedures

Managing expectations for school demands in a Managing expectations for school demands in a student that is there in school “looking OK”student that is there in school “looking OK”

When does a student stay home, when does a When does a student stay home, when does a student return to school (criteria for partial vs full day)student return to school (criteria for partial vs full day)

How are you monitoring recovery across the day and How are you monitoring recovery across the day and across the week (hint – use a sx monitoring tool)across the week (hint – use a sx monitoring tool)

Where/ how will you provide key accommodations?Where/ how will you provide key accommodations? Rest breaksRest breaks Managing tests, AssignmentsManaging tests, Assignments GradingGrading

What can I do to prepare for a concussion?

Prepare a concussion action plan. To ensure that concussions are identified early and

managed correctly, have an action plan in place before the start of the school year.

This plan can be included in your school or district’s concussion policy.

Be sure that other appropriate school and athletic staff know about the plan and have been trained to use it.

What can I do to prepare for a concussion?

Educate parents, teachers, coaches, and students about concussion.

Parents, teachers, and coaches know their students well and may be the first to notice when a student is not acting normally.

Encourage teachers, coaches, and students to: Learn about the potential long-term effects of concussion

and the dangers of returning to activity too soon. Look out for the signs and symptoms of concussion and

send students to see you if they observe any or even suspect that a concussion has occurred.

Keep students with a known or suspected concussion out of physical activity, sports, or playground activity on the day of the injury

AND until a health care professional with experience in evaluating for concussion says they are symptom-free and it is OK for the student to return to play.

What can I do to prepare for a concussion?

Monitor the health of your student athletes. Make sure to ask whether an athlete has ever had

a concussion and insist that your athletes are medically evaluated and are in good condition to participate in sports.

Keep track of athletes who sustain concussions during the school year. This will help in monitoring injured athletes who participate in multiple sports throughout the school year.

What can I do to prepare for a concussion?

Small Group Work

Small Group Work

Small Group Work

Concussion/ mTBICDC Educational Materials

Heads Up: Concussion in High School Sports

Heads Up: Concussion in Youth Sports

Heads Up: Concussion in Your Practice

Heads Up to Schools: Know Your Concussion ABCs

www.cdc.gov/concussion

Educational Materials

Coaches, Parents, Student-athletes Coaches, Parents, Student-athletes Video Education: Video Education:

www.nanonline.org

www.concussion.orcas.com

www.usafootball.com

www.nfhslearn.org Fact SheetsFact Sheets Clipboard stickersClipboard stickers

Public Awareness &

Education

Video EducationCoaches, Parents, Athletes

.                             

USA Football

ACTive: Free Concussion Training for Sports

Coaches

Play Smart: Understanding

Sports Concussion

NAN-NATA w NFL/NHLRaising Concussion Awareness

Educational DVD, "Concussions in Football (Hockey): Signs,

Symptoms and Playing  Safe"

Concussion Clipboard

Electronic Clipboard

Coach/ Parent Electronic ClipboardCoach/ Parent Electronic Clipboard

Using Technology to AssistConcussion Symptom

Management

9:30am

Alert: Your symptoms are worsening. Time for

a rest break.