RETURN TO LEARN AFTER CONCUSSION

Matthew Hall, D.O.

Assistant Professor, Sports Medicine

Director, UConn Sports Concussion Program

Medical Director, UConn Club Sports

UConn Health, Dept. of Orthopedics

New England Musculoskeletal Institute

Objectives

Recent evidence on cognitive rest in treatment of concussions.

Review “best practices” and guidelines regarding return to learn.

Discuss school adjustments and accommodations for students with concussion

Return to Learning

“Majority of the focus on concussions has been centered on diagnosis, education of key stakeholders regarding the problem, and the timing of safe return to play” (Halstead et al.)

No standardized guidelines, guidelines based on “expert opinion”

Determined by the health care provider

Individualized treatment plan

Return to Learn

No consensus guidelines Neurocognitive deficits may persistent

despite being asymptomatic Students with increased symptoms with

school may require :○ Reduced work load○ Extended test-taking time○ Days off from school○ Shortened school days

AAP Recommended Approach

Return to learn if able to tolerate light mental exertion for 30 minutes

Standard class/period lengths 30-45 minutes in length

Short periods of rest between classes may be necessary vs. dismissal when symptomatic

Cognitive Rest

Accepted practice & treatment for concussion

What is the evidence for cognitive rest as a treatment for concussion?

How much cognitive rest is enough?

How do you define cognitive rest?

Definition of Cognitive Rest (Moser et al.)

Time off from school No homework No reading No visually stimulating activities No exercise No social visits Increased rest & sleep

Studies on Cognitive Rest

Moser et al. Efficacy of Immediate and Delayed Cognitive Rest for Treatment of Sports-related Concussion. The Journal of Pediatrics (2012)

Retrospective cohort (N = 49)Prescribed cognitive restAll had improved ImPact scores with restEven those with prolonged symptoms still

showed improvement with rest

Studies on Cognitive Rest

Gibson et al. The Effect of Recommending Cognitive Rest on Recovery from Sports-related Concussion. Brain Injury (2013)

Retrospective chart review (N = 135)Primary outcome = duration of post-concussive

symptomsLooked to see if cognitive rest was within the

provider’s plan in the medical recordNo associated between length of symptoms and

whether or not cognitive rest was prescribed

Studies on Cognitive Rest

Brown et al. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Pediatrics (2014)

Prospective Cohort (N = 335)Primary outcome = duration of symptoms

associated with “cognitive activity-days”Cognitive activity-days = average cognitive

activity level x days between visitsPatients self-reports their cognitive activity level

Brown et al. Cognitive Scale

Duration of symptoms by quartile of cognitive activity-days.

Brown N J et al. Pediatrics 2014;133:e299-e304

©2014 by American Academy of Pediatrics

How to “prescribe” cognitive rest?

Relative cognitive rest, not “bubble” therapy

Avoid noisy public locations i.e. restaurants Limit screen time No headphones Short periods of an activity i.e. reading

Start with less strenuous i.e. magazine and not AP homework

Symptoms increasing? Stop, rest, and remember the threshold

School Considerations

Consider each student-athletes needs

Include detailed school note regarding accommodations and adjustments

Difficult cases may require discussion with school or more of a multi-disciplinary approach

Team Approach

Communication between school, physician, and athletic trainerChallenge! Particularly in the office

setting…Need to abide by FERPA & HIPAA

Multi-disciplinary team necessary for prolonged symptoms and post-concussive syndrome

Adjustments vs. Accommodations (Halstead et al.)

“Adjustments”Initial recovery period, first 1-3 weeksNo formal change to student school

environment

“Accommodations”Symptoms > 3 weeksStandardized test changes, extended time

for tests & assignments, schedule changesFormalized with a 504 plan

504 Plan

From Section 504 of Rehabilitation Act and Americans with Disability Act

Students who require accommodations because of a medical diagnosis but do not qualify for an IEP

Can be requested by provider

Individualized Education Plan (IEP)

Allows for “modification” to students education and dictates what services should be provided to the student

Protected under the Individuals with Disabilities Education Act

Testing to determine if student requires and IEP can be requested by the family or the school

History Considerations

Learning disability? Multiple concussions? Concussion with prolonged symptoms? Immediately removed from sport? Depression or anxiety? Mood Disorder? Migraines? Family stressors? School pressures or testing?

My Practice Primarily high school age Out of school for 3-4 days, using the

calendar to my advantage Try to integrate back to school as soon as

possible Detailed school note Start as half days if can tolerate, early on

more about getting them back to their routine Progress to full days as able to tolerate Follow-ups early and often

What can we do better?

Communication with schools:School nurses and/or ATC to help monitor and

manage symptomsCounselor or psychologist to help the

accommodations and transitioning to full time school

• Education and awareness for providers seeing concussions, better guidelines to aid in return to learn Individualized “return to learn” plan

References Harmon KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring

SA,Kutcher JS, Pana A, Putukian M, Roberts WO. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013 Jan;47(1):15-26.

Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K; Council on Sports Medicine and Fitness; Council on School Health. Returning to learning following a concussion. Pediatrics. 2013 Nov;132(5):948-57.

Gibson S, Nigrovic LE, O'Brien M, Meehan WP 3rd. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj. 2013;27(7-8):839-42.

Moser RS, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. J Pediatr. 2012 Nov;161(5):922-6.

Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP 3rd. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014 Feb;133(2):e299-304.

Majerske CW, Mihalik JP, Ren D, Collins MW, Reddy CC, Lovell MR, Wagner AK. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008 May-Jun;43(3):265-74.