1. Successful Return-to-Learn after Concussion Kristi Pardue, MS, CCC-SLP, CBIS Manager, St. Luke’s Sports Medicine Concussion Clinic IATA Annual Summer Symposium- July 26, 2014

2. Talking Points
Discuss concussion symptoms and their direct impact on academics
Discuss how to utilize return-to-learn for student athletes after concussion
Discuss academic adjustments
Review the 504 plan process and benefit to students
Discuss successful team member communication

3. “The majority (80-90%) of concussions resolve in a short (7-10 day) period, although the recovery time frame may be longer in children and adolescents.”
“Concussion is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage.”
McCroy P, et al. Br J Sports Med 2013

4. Student Athlete

5. Education & Collaboration
Multidisciplinary Team to Facilitate “Return to Learning” Pediatrics Vol. 132, Number 5, Nov. 2013
Education & Collaboration
Supporting Students
School Team - Physical
Coaches
Athletic Trainers
School Nurse
PE Teacher
School Team – Academic
Teachers
Nurse
Counselor
Administrators
School Psychologist
Medical Team
Emergency Department
Primary Care Provider/Pediatrician
Concussion Specialist
Neuropsychologist
Family Team
Parents
Student
Grandparents
Peers
Teammates
Family Friends
All of these people involved. First part is education of all parties next part is communication.

6. Common Symptoms
PECS
Physical
Emotional
Cognitive
Sleep

7. Physical Emotional Headache Nausea Vomiting Balance problems Dizziness
Visual problems
Fatigue
Sensitivity to light
Sensitivity to noise
Emotional
Irritability
Sadness
More emotional
Nervousness

8. Cognitive Sleep Feeling mentally foggy Slowed thinking
Difficulty concentrating
Difficulty remembering
Sleep
Drowsiness
Sleeping less than usual
Sleeping more than usual
Trouble falling asleep

9. Most Common “Thinking” Cognitive Problems Post Concussion
Fatigue, specifically Mental fatigue
Difficulty concentrating
Slowed processing speed
** feels like being converted from high speed internet to dial up internet
Difficulty with working memory
**The ability to temporarily store and manage information during complex cognitive processes such as learning and reasoning
Difficulty converting new learning into memory
Emotional symptoms
McAvoy, K., The REAP Project Rocky Mountain Youth Sports Medicine Institute

10. Secondary Problems Depression or anxiety
Can emerge or increase due to medical distress and uncertainty, or due to inability to participate in sport or other social activities.
Academic stress
Social isolation

11. Balancing Medical Needs & Academic Needs

12. RTL & RTP In order to return-to-play, students must be symptom free.
This does not apply to return-to-learn. We want to ensure returning to learn doesn't worsen symptoms, but they do not have to be symptom free before starting this process. The longer we keep students out of school, the harder it is to transition back from an academic, as well as a social perspective.
Increasing evidence that children and adolescent patients benefit from a controlled, gradual return-to-learn approach, rather than an attempt to return to full school load after cognitive rest has resulted in symptom reduction. Master, Gioia, Leddy and Grady Pediatric Annals Sept
Follow-up calls Monday at 8:00 am. Return by 12:00 after received a call from the school RN to pick up child.

13. Return-To-Learn Plan Stage Activity Objective No Activity
Complete cognitive rest-no school, no homework, no reading, not texting, no video games, no computer work
Recovery
Gradual reintroduction of cognitive activity
Relax previous restrictions on activities and add back for short periods of time (5-15 minutes at a time).
Gradual controlled increase in subsymptom threshold cognitive activities.
Homework at home before school work at school
Homework in longer increments (20-30 minutes at a time).
Increase cognitive stamina by repetition of short periods of self-paced cognitive activity.
School re-entry
Part of school after tolerating 1-2 cumulative hours of homework at home.
Re-entry into school with accommodations to permit controlled subsymptom threshold increase in cognitive load
Gradual reintegration into school
Increase to a full day of school.
Accommodations decrease as cognitive stamina improves.
Resumption of full cognitive workload
Introduce testing, catch up with essential work.
Full return to school; may commence Return-to-Play protocol.
Source: Master, Gioia, Leddy, Grady

15. Teacher, RN, Counselors, understanding concussions so understand adjusments

17. Helping Students Recover from a Concussion: Classroom Tips for Teachers CDC concussion resources
Key Points:
Work with students and their parents to identify the type and length of activities your students can handle and create a plan on how to address any school work they may have missed.
Tailor the plan to each student. Take into account your student’s age, type of symptoms, level of understanding, and emotional status. No two students are alike in the concussion symptoms they have and how they recover from a concussion.
Coordinate the classroom changes with your students’ other teachers and other school professionals, so they have the same level of support throughout the school day.

18. Helping Students Recover from a Concussion: Classroom Tips for Teachers CDC concussion resources

19. Others to Consider
Student agenda to be used by student to track assignments, test dates, and communication log between student, teacher and parents.
Non-essential work not to be made up so that student can keep up.
Student is not to have more than 2 hours of homework per evening.
Student is not to take more than one test/exam on the same day.
State tests-should be delayed or excused until they are asymptomatic.
Fire drills

20. When is it time to consider more structured accommodations?

21. 504 Accommodation Plans Definition-
Section 504 of the Rehabilitation Act of 1973
Civil Rights Law
Purpose is to protect the rights of individuals with disabilities in programs and activities that receive federal assistance from the Dept. of Education.
Eligible when have a physical or mental impairment which substantially limits one or more major life activities.
**Levels the playing field; providing a comparable opportunity.
Qualification
Identify-parents, teachers, doctors, student, nurse, counselor
Evaluate- disability? Individual needs?
Placement-team decision based on qualifying factors

22. 504 Accommodation Plans Purpose
the 504 protects the student’s rights by providing a formal document to ensure all teachers, parents, coaches, school staff members are on the same page regarding the student’s needs. And most importantly, the student.
Benefits
structure and communication
Time frame
appropriate to implement a 504 Plan as long as a student exhibited or reported symptoms that might limit his/her ability to learn.
In place and review at least on yearly basis. Concussion is more dynamic so need to review more frequently. Complex cases request meeting in 2 weeks.
Grades aren’t the determining factor.

23. Education & Collaboration
Multidisciplinary Team to Facilitate “Return to Learning” Pediatrics Vol. 132, Number 5, Nov. 2013
Education & Collaboration
Supporting Students
School Team - Physical
Coaches
Athletic Trainers
School Nurse
PE Teacher
School Team – Academic
Teachers
Nurse
Counselor
Administrators
School Psychologist
Medical Team
Emergency Department
Primary Care Provider/Pediatrician
Concussion Specialist
Neuropsychologist
Family Team
Parents
Student
Grandparents
Peers
Teammates
Family Friends

24. Standardized Process of Communication
Explain your role in caring for the student athlete. Ongoing communication from diagnosis to clearance.
School RN
Teachers
Counselors
Parents
What is the best way to communicate?
How can everyone work together to keep an eye on student in each environment?
Advocate for ATC services by increasing schools awareness in important role you play. Respecting that you can’t be with student all day. May do well in one class, but by end of the day symptoms increase.
Several school RNs ask “if returned to play are we to assume cleared for full academics?” ** Consider meeting with school RN, counselor, teachers at beginning of year to develop plan of communication so they know what to expect?

25. Ongoing Communication Needs
Any member of the team who is under-informed reduces the chance for success.
Daily and weekly communication.
The student may not be the best reporter or historian, in their current condition.
Feedback is essential from all parties – request feedback if it has not already been addressed.
Not every concussion is the same – we learn something new nearly every time.
Ongoing communication to all team members as student recovers with documentation completed as needed.
Final physician clearance once fully back to school.

26. Consistent Messaging Regarding Return to Learn

27. Collegiate Level Athletes
LEARNING SUPPORT & DISABILITY SERVICES

31. Kristi Pardue M.S.,CCC-SLP,CBIS
Manager, St. Luke’s Sports Medicine Concussion Clinic
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