1. Concussion
In the School Setting

2. Presentation Objectives
Define concussion
Review the Missouri Interscholastic Youth Sports Brain Injury Prevention Act 
Understand common signs and symptoms of concussion and when to call 911
Describe Return to Learn Team Concept / handouts
Describe Return to Play Guidelines
Understand Academic Adjustments vs. 504 Plan vs. IEP
Improve school nurse practice by assembling concussion resources

3. Aubry et. al., Br J Sports Med 36(1): 6-10, 2002
Concussion Defined
Traumatic brain injury (TBI) caused by a bump, blow, or jolt to the head and alters the way the brain functions.
Concussions can also occur from a fall or a blow to the body that causes the head and brain to move quickly back and forth.
Aubry et. al., Br J Sports Med 36(1): 6-10, 2002

4. Concussion Concussion may or may not involve a loss of consciousness
Typically, no abnormality noted on standard structural neuro- imaging
Resolution of clinical and cognitive symptoms typically follows a sequential course however, a small percentage of individuals experience enduring symptoms

5. Epidemiology: Boys Sports
Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958–963; Castile L, Collins CL, McIlvain NM, et al. The epidemiology of new versus recurrent sports concussions among high school athletes, Br J Sports Med. 2012;46(8):603–610; and Marar M, McIlvain NM, Fields SK, et al. Epidemiology of concussion among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(40):747–755

6. Epidemiology: Girls Sports
Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958–963; Castile L, Collins CL, McIlvain NM, et al. The epidemiology of new versus recurrent sports concussions among high school athletes, Br J Sports Med. 2012;46(8):603–610; and Marar M, McIlvain NM, Fields SK, et al. Epidemiology of concussion among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(40):747–755

7. Severity of TBI ranges from
Mild TBI (Concussion) Severe TBI

8. If a TBI compromises oxygen to parts of the brain, it may
Primary injuries… skull fractures, contusions, Intracranial hemorrhage, or a diffuse axonal injury
Secondary injuries evolve following the initial trauma (such as a brain bleed, swelling or post traumatic epilepsy)
If a TBI compromises oxygen to parts of the brain, it may
result in changes in intracranial pressure, heart rate, blood
pressure, and nutritional state.
Vital signs should be part of your assessment
Contusions may result in bleeding or swelling on the side of impact or the opposite side

9. Research Tells us…
Not all concussions get better in a week
Majority of concussions from sports occur in school aged individuals
Cognitive function may be affected following a concussion
Environmental triggers (light/noise) may provoke symptoms
There is lack of communication between healthcare providers and the schools

10. Missouri HB 300
“Interscholastic Youth Sports Brain Injury Prevention Act” Effective date: 8/28/2011
Concussion and brain injury information given and signed for by the athlete and parent/guardian on a yearly basis prior to participation
Athlete suspected of sustaining a concussion or brain injury is removed from competition/practice for no less than 24 hours

11. Injured athlete may not return to play until evaluated by licensed health care provider and receives written clearance to return to competition
School district is responsible for publishing an annual report detailing efforts that may be made to minimize damages from injuries sustained by students participating in school sports

12. Head Injury Assessment
Complete concussion history
Athlete description of injury and symptoms
3rd Party description of injury and symptoms
Observed symptoms

14. Call 911 if… One pupil larger than the other
Is drowsy or cannot be awakened
A headache that gets worse and does not go away
Weakness, numbness, or decreased coordination
Repeated vomiting or nausea
Slurred speech
Convulsions or seizures
Cannot recognize people or places
Becomes increasingly confused, restless, or agitated
Has unusual behavior
Loses consciousness (even a brief loss of consciousness should be taken seriously)

15. Concussion affects learning, and the stress of learning can affect the symptoms associated with concussion.

16. “The goal following concussion is to keep disruptions to the child’s life to a minimum and to return the child to their regular school routine asap.”
Dr. Mark Halstead, MD

17. Brain rest
Initially restrict physical activity that increases heart rate or blood pressure
P.E./Recess
Sports
Working Out
Recreational Activities (skateboarding, etc.)
These restrictions change based on improvement of symptoms.
Returning to the Classroom Following a Concussion - Mark Halstead, MD
Director, Sports Concussion Clinic, 2017 MO-BIAA Concussion Facts and Fallacies

18. Brain Rest Consider reducing cognitive stress
Reduced school load/homework
Untimed tests
Environmental adjustments (noise, seating, etc.)
May need to limit video games, texting, reading, computer use, TV
Electronics can be an advantage – (increased font size, dim screen)
Consideration for restrictions on driving  reduced reaction time is issue
Do not treat concussion as a punishment
Returning to the Classroom Following a Concussion - Mark Halstead, MD, Director, Sports Concussion Clinic, 2017 MO-BIAA Concussion Facts and Fallacies
There is no evidence based research to suggest screens truly are bad. Todays kids are super connected.

19. Returning to School takes an Individualized Plan
Medical
Family
School teams:
School nurse, counselor, teachers
The challenge… finding balance with a multidisciplinary team.

21. Healthcare Provider Role
Understand and respect school terminology and resources
Realize return to learn recommendations do NOT have to be followed by the school. There is no legal obligation to do so.
If you a healthcare provider makes recommendations, stress with family and student that it is up to the family to communicate with the school and the adjustments will be fluid
Work with schools. Educate when appropriate.
Physicians were not taught in medical school how to manage school days for kids.
Returning to the Classroom Following a Concussion - Mark Halstead, MD Director, Sports Concussion Clinic, 2017 MO-BIAA Concussion Facts and Fallacies

22. Role of the School
Encourage communication from the student regarding their symptoms
Implement adjustments for students even before the note comes from the doctor
ATCs – Communicate with the nurse/counselor regarding the diagnosis and encourage adjustments to start early
School nurses – use a symptom checklist if evaluating students and let teachers know what symptoms are reported
PE teachers – Avoid having the kids do assignments to substitute for their missed work.
Returning to the Classroom Following a Concussion - Mark Halstead, MD, Director, Sports Concussion Clinic, 2017 MO-BIAA Concussion Facts and Fallacies

23. What Research Tells Us
Kids kept on strict rest at home for 5 days compared to kids who return to school with modifications
Strict rest kids have more symptoms and take longer to get better than kids who were back in school with adjustments
Kids who were allowed extremes - no activity (mental or physical) or complete activity
Performed worst on neuro-psych tests than those kids who were doing light physical activity and some academic work
Kids who don’t make any adjustments in school at all
Take the longest to get better
All other groups recovered at similar rate
Returning to the Classroom Following a Concussion - Mark Halstead, MD, Director, Sports Concussion Clinic, 2017 MO-BIAA Concussion Facts and Fallacies

24. Return to Learn
Academic Adjustment - Non-formalized adjustments made to the student’s environment that do not jeopardize the curriculum or require alterations in standardized testing. Academic Accommodation – longer-term needs (usually >3 weeks) which may include changes to schedule, extra time on work, but still within context of regular education. Can be formalized in 504 plan Academic Modification – more prolonged and possibly permanent changes to educational plan, necessitating special education with needs specified in an IEP.

25. Signs / Symptoms
Potential Academic Adjustment
Headache
Frequent breaks
Identify trigger and reduce exposure
Rest prn in nurses office or quiet area
Dizziness
Allow student to rest head if symptoms worsen
Early passing to avoid crowded hallway
Light sensitivity
Reduce brightness of screen
Allow hat or sunglasses
Consider use of audio-taped books
Turn off fluorescent light prn

26. Signs / Symptoms
Potential Academic Adjustment
Noise sensitivity
Limit or avoid band, choir, or shop class
Avoid noisy gym or organized sports practices/games
Consider use of ear plugs
Early passing to avoid noisy crowded hallway
Memory Difficulty
Avoid testing or completion of major projects during recovery when possible
Provide extra time to complete non-standardized tests
Consider one test per day during exam periods
Consider the use of pre-printed notes, note taker, scribe, or reader for oral test taking.
Sleep Problems
Allow for late start or shortened day to catch up on sleep
Allow for rest breaks

27. Return to Learn… Possible 504 Accommodations
Students who return to school after a concussion may need to:
•Take rest breaks as needed,
•Spend fewer hours at school,
•Be given more time to take tests or complete assignments,
•Receive help with schoolwork,(tutoring) and/or
•Reduce time spent on the computer, reading, or writing.
504 needs to be specific to symptoms.

28. Given expected recovery for concussion….
504 Plans and IEP’s should be used extremely rare
Even requesting one requires school to go through the effort
504 and IEP’s take time to implement
Homebound should be avoided if possible
If school is encouraging homebound, often it is a school who doesn’t understand how to apply adjustments they already do to other students

29. Considerations if student is not improving…
Cervical Injury
Depression/Anxiety
Vestibular Deficiencies
Visual system/Oculomotor Deficiencies
Sleep/Circadian Rhythm Disorder
Conversion of undiagnosed migraine disorder
Malingering
Consider “PTSD-like” if bullying was reason for concussion

30. Return PE / Sports / Recess
Children and teens with a suspected concussion should NEVER return to sports , recreation activities, recess, or PE on the same day the injury occurred.
They should delay returning to their activities until a health care professional experienced in evaluating for concussion says they are symptom-free and it’s OK to return to play.

31. Return to Play Plan Stage 1: No physical activity until symptom free
Stage 2: Light exercise - walking, (light jogging, stationary bike)
Stage 3: Moderate levels of activity – running gym or field
Stage 4: Non-contact training drills, weight lifting
Stage 5: Full contact in controlled practice
Stage 6: Full contact in game

32. Things to remember… Helmets and mouth guards do not prevent concussion
“Biggest hits” may not correlate with greatest experience of concussion
Repeated concussion may lead to long-term consequences in some individuals
Leading with the head and special team play contributing factors in Football related concussions

33. Resources Brain Injury Association of Missouri http://www.biamo.org/
Returning to the Classroom Following a Concussion - Mark Halstead, MD, Director, Sports Concussion Clinic, 2017 MO-BIAA Concussion Facts and Fallacies
Brain Injury Association of America
Center for Disease Control (CDC)
Center for Disease Control (CDC) Coaches Guide

34. Resources Missouri State High Schools Activity Association
National Association of School Nurses Position Statement
the-role-of-the-school-nurse
National Athletic Trainers Association
American Academy of Pediatrics

35. Questions / Comments