1. Return to Learning Following Sports Related Concussion Michael de Riesthal, Ph.D., CCC-SLP Pi Beta Phi Rehabilitation Institute Vanderbilt University Medical Center

2. Overview Return to Learning Recommendations-2013 Return to Learning Recommendations-2016 Are accommodations implemented and do they help? Management of the Complex Patient

3. Definition: Concussion Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. McCrory, Meeuwisse, Aubry, et al. (2013)

4. AAP 2013 Clinical Report The goal is to return to school as quickly as possible to minimize disruption without placing demands on students that exacerbate symptoms.

5. Halstead, McAvoy, Devore, et al. (2013) Return to Learning Team “It remains essential that all schools recognize the importance of team management for a student after concussion and ensure that all students recovering from concussion have assigned staff who will be responsible for smooth reentry to school.”

6. Multidisciplinary Team Halstead, McAvoy, Devore, et al. (2013)

7. Strategies for RTL First 1 to 3 weeks of recovery focus on “academic adjustments” in general classroom Beyond 3 weeks, may need “academic accommodations” in general classroom More permanent “academic modifications” may be needed if symptoms persist Halstead, McAvoy, Devore, et al. (2013)

8. Halstead, McAvoy, Devore, et al. (2013) p. 954

9. Strategies for RTL First 1 to 3 weeks of recovery focus on “academic adjustments” in general classroom Beyond 3 weeks, may need “academic accommodations” in general classroom More permanent “academic modifications” may be needed if symptoms persist Halstead, McAvoy, Devore, et al. (2013)

11. Strategies for RTL First 1 to 3 weeks of recovery focus on “academic adjustments” in general classroom Beyond 3 weeks, may need “academic accommodations” in general classroom More permanent “academic modifications” may be needed if symptoms persist Halstead, McAvoy, Devore, et al. (2013)

12. Overview Return to Learning Recommendations-2013 Return to Learning Recommendations-2016 Are accommodations implemented and do they help? Management of the Complex Patient

13. “There are considerable individual differences in the rate at which students are ready to return to school following injury, with some returning immediately and fully and others returning gradually with accommodations.” Phys Med Rehabil Clin N Am (2016)

14. Iverson & Gioia (2016) Recommendations Return to school during the first week following injury and, if symptomatic, encourage accommodations If not returned in 2 weeks should be evaluated carefully – prolonged absence from school can have significant negative effects Several different accommodations might be reasonable and necessary during the initial days, and sometimes weeks, following injury.

15. Cognitive and Psychological Sequelae Contextualized Collaborative Hypothesis Testing Iverson & Gioia (2016)

16. What does this mean? Contextualized Collaborative Hypothesis testing Assess real-world tasks Consider the opinions of multiple sources for possible causes of problems Test the influence of possible causes in systematic manner

17. Contextualized Collaborative Hypothesis Testing Generate assessment question Collaborative hypothesis generation Collaborative hypothesis testing * Collaboration includes the patient, family, and all members of the rehabilitation team. ASHA technical report (2003) Ylvisaker & Feeney (1998)

18. Hypotheses? Physical problems Sensory/perceptual problems Cognitive problems – Attention – Memory – Orientation – Organization/integration – Speed of information processing Language problems Academic problems Emotional/motivational /behavioral problems ASHA technical report (2003) Ylvisaker & Feeney (1998)

19. What Hypothesis Do You Test First? Choose based on – Likeliness of confirmation – Importance of the hypothesis – Ease of testing ASHA technical report (2003) Ylvisaker & Feeney (1998)

20. Accommodations and Strategy Development Iverson & Gioia (2016)

21. Concussion Activity Exertion Management Set the positive foundation – Framing injury in positive, progressive, reassuring manner; providing appropriate education Define the parameters of activity-exertion – Define schedule, potential challenges, and limits of tolerability Teach activity-exertion monitoring – Moderated activity, symptom monitoring, work to tolerable limits Reinforce progress – Recovery is dynamic; ramp up activity with increased tolerance Iverson & Gioia (2016)

22. Overview Return to Learning Recommendations-2013 Return to Learning Recommendations-2016 Are accommodations implemented and do they help? Management of the Complex Patient

23. Are Accommodations Recommended and Implemented? Accommodations are widely recommended, but there are limited data regarding whether they are implemented and to what effect A single study showed that 56% of high school athletes received school-based accommodations post-concussion Recommendation of accommodations is related – to parent and child symptom report and neurocognitive testing – to reduction of concern regarding academics at follow up Kirkwood, 2008; Sady, 2011; Master, 2012; DeMatteo, 2015; Glang, 2015; Vaughan, 2014

24. Wilson (2016): Return to School after Sports-Related Concussion Participants: Youth ages 13-17 who presented to the Vanderbilt Sports Concussion Center (VSCC) after sustaining a sports- related concussion.

25. Methods Return to school telephone survey administered to caregiver/parent and adolescent with concussion Injury information extracted from the medical record and ImPACT database Wilson, 2016

26. Return to School Questionnaire Demographics: Family income, parent education child age, sex Pre-concussion factors: Medical history, school supports, perceived academic performance Concussion factors: Concussion history, concussion event and effects, concussion severity Outcomes:Absences, perceived change in academic performance, receipt of accommodations, satisfaction Wilson, 2016

27. Aim 1: Describe school outcomes Absences – Average of 2 absences reported Return to academic baseline – 86.7% (n=72) of parents and 92.3% (n=72) of children reported return to baseline No grade retention Wilson, 2016

28. Aim 2: Describe accommodations Parent report: – 73.5% (n=61) of children received at least 1 academic accommodation Child report – 76.9% (n=60 ) of children received at least 1 academic accommodation Wilson, 2016

29. Most frequent accommodations following concussion Parent report Extended time to complete tasks (62.6%) Staggered or postponed tests (33.7%) Shortened school days (33.7%) Reduced workload (32.5%) Child report Extended time to complete tasks (56.4%) Staggered or postponed tests (44.9%) Reduced workload (30.8%) Time to visit the school nurse (30.8%) Wilson, 2016

30. Aim 3: Describe satisfaction With accommodations Parent report – 81.9% (n=68) satisfied or very satisfied Child report – 82.1% (n=64) satisfied or very satisfied With return to school exp erience Parent report 89.2% (n=74) satisfied or very satisfied Child report 85.9% (n=67) satisfied or very satisfied Wilson, 2016

31. Aim 4: Relationship among outcomes Parent report Child report Wilson, 2016

32. Overview Return to Learning Recommendations-2013 Return to Learning Recommendations-2016 Are accommodations implemented and do they help? Management of the Complex Patient

33. Complicated Patients Persisting symptoms in 10-15% of patients May be mediated by concussion “modifiers” – Influence the management of concussion – May predict potential for prolonged or persistent symptoms McCrory, Meeuwisse, Aubry, et al. (2013)

34. Management of Persistent Symptoms Following period of physical and cognitive rest May benefit from – Cognitive therapy – Vestibular rehabilitation – Oculomotor rehabilitation – Psychological therapy McCrory, Meeuwisse, Aubry, et al. (2013)

35. Psychoeducational, Cognitive, & Psychological Therapy Several systematic reviews – World Health Organization (WHO) Collaborating Centre Task Force (Borg et al., 2004) – Comper and colleagues (2005) – Snell and colleagues (2009) Provide tentative support for educational approaches, but highlight the absence of rigorous intervention studies in general

36. Vestibular Rehabilitation Vestibular therapies include eye-head coordination; sitting, standing static, and standing dynamic balance; and ambulation exercises The vestibular rehabilitation programs typically 4 – 8 weeks in duration

37. Vestibular Rehabilitation Several studies have demonstrated that – vestibular rehabilitation following concussion may reduce dizziness and improve gait and balance (Alsalaheen et al. 2010) – following an 8-week trial the SRC group that received cervical spine and vestibular rehabilitation were nearly four times more likely to be medically cleared than the control group (Schneider and colleagues, 2014)

38. Oculomotor Rehabilitation Initial evidence supports targeted oculomotor and vision rehabilitation therapies. Studies have shown – oculomotor therapies resulted in 90 % of patients improving markedly or completely in symptoms and impairment (Ciuffreda et al., 2008) – enhanced reading following treatment and were sustained out to a 2 to 3-month follow-up time period. – accommodative responsivity and versional eye movements following oculomotor training (Thiagarajan et al, 2014a, b)

39. Review Return to Learning Recommendations-2013 Return to Learning Recommendations-2016 Are accommodations implemented and do they help? Management of the Complex Patient

40. Thank you