1. Concussions and the Road Back to the Classroom
Gerard A. Gioia, Ph.D.
Pediatric Neuropsychologist
Chief, Division of Pediatric Neuropsychology
Director, Safe Concussion Outcome, Recovery & Education (SCORE) Program
Children’s National Medical Center
Washington, DC

2. Disclosure Test Author
Behavior Rating Inventory of Executive Function (BRIEF) Psychological Assessment Resources, Inc.
Tasks of Executive Control (TEC)
Pediatric Immediate Post-Concussion Assessment and Cognitive Testing (Pediatric ImPACT)
Acute Concussion Evaluation (ACE)
Concussion Recognition & Response App
Concussion Assessment & Response (CARE) App

3. Plan for the Day Concussion 101: What is it?
Effects of Concussion on School Learning & Performance
Effects of School Learning & Performance on Concussion Recovery
Strategies for Supporting Recovery
Q&A
Break
Small Groups: Examining your concussion policies & procedures, developing/ expanding
Large Group: Discussion of policies & procedures; Q&A

4. “Your Brain is Your Future”
(and the source of your parents’ retirement…)

5. A concussion is a brain injury

6. Brain injuries threaten the Child’s future

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

8. Who’s on the Team?

9. Four Corners Approach to Concussion Care
Medical Systems
Family
Pre-Hospital (EMS) Emergency
Urgent
Primary Care
Specialty Care
Child/ Teen
(Student, Athlete, Son/Daughter,
Friend)
Certified Athletic Trainer
Certified Athletic Trainer
School
Athletic/ Recreational
Administrators
Teachers
Certified Athletic Trainer
Administrators
Coaches
Officials
Parents
Teammates
School Nurse/ Counselor
Psychologist

10. What is a Concussion?
A concussion is an injury to the brain caused by a direct blow to the head, face, neck or elsewhere on the body that causes the head and brain to move rapidly back and forth.
A concussion results in the onset of impaired brain function, producing a set of clinical signs and symptoms (physical, cognitive, emotional, sleep) that may or may not involve loss of consciousness.

11. What is a Concussion?
Recovery of the clinical and cognitive symptoms typically follows a sequential course over a period of days to weeks.
In a small percentage of cases, post-concussive symptoms may be prolonged for months or longer.
Typically, no abnormality on standard structural neuroimaging studies (CT, MRI) is seen in a concussion.

13. Effects of Concussive Forces on the Brain
Typically, the “software” of the brain is affected
Neurometabolic/ neurochemical processes
Physiological
Not the “hardware”
Structure

14. Neurometabolic Cascade Following Traumatic Brain Injury
(Giza & Hovda, 2001) 2 6 12 20 30 24 3 10
minutes
hours
days
500
400
300
200 50
100
% of normal
Calcium K+
Glucose
Glutamate
Cerebral Blood Flow
UCLA Brain Injury Research Center

15. Signs You May See (Acutely)

17. Recovery From Concussion: How Long Does it Take?
WEEK 5
WEEK 4
WEEK 1
WEEK 3
WEEK 2
N=134 High School athletes
Collins et al., 2006, Neurosurgery

18. Focus on School Return & Support

19. "You can't educate a child who isn't healthy, and you can't keep a child healthy who isn't educated."   
Joycelyn Elders

21. Effect of Concussion on School Learning & Performance
Effect of School Learning & Performance on Concussion Recovery

22. School Kid’s Major “Job”
New Learning/ Acquiring Knowledge
Academic
Social
Practicing incompletely learned knowledge
Mental/ Cognitive exertion is essential to new learning/ practice 22

23. 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

24. Concussion’s Effects on School Learning & Performance
80 students with concussions
“Which specific types of problems are you experiencing in school?”
Students reported an average of 4 problems below.
Headaches interfering %
Can’t pay attn in class %
HW taking much longer %
Difficulty studying for test/quiz 51.9%
Too tired %
Diffic understanding material 44.0%
Difficulty taking notes %

25. Concussion’s Effects on School Learning & Performance
“Which classes are you having the most trouble with?”
(Percent reporting trouble in class)
Parent Student
Math % %
Reading/LA 38.1% %
Science % %
Soc Stud 38.1% %
Foreign Lang 38.1% %
Music % 17.9%
PE % 10.5%
Art % 5.3%
-None 25.4% %

26. Effect of School Learning & Performance on Concussion Recovery

27. Cognitive Demands of School Worsen Symptoms
N= 72 Gioia et al., 2010

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

29. Sources of Mental/ Cognitive Activity?
Prolonged concentration
Prolonged homework
Prolonged classes (block scheduling)
Prolonged days
Excessive TV, computer, socializing…
These sources and degrees of activity are likely to vary from person to person

30. Keys to Recovery Ways to over-exert
Resting the brain & getting good sleep
No additional forces to head/ brain
Managing/ facilitating physiological recovery
Avoid activities that produce symptoms
Not over-exerting body or brain
Ways to over-exert
Physical
Emotional
Cognitive! (concentration, learning, memory)

31. “Physical rest alone fails to address another key aspect of brain function in youth – mental exertion associated with school activities.”
Athletic Therapy March, 2010

32. What is cognitive “rest?”
The concept of cognitive exertional activity (and rest) viewed along a continuum of activity
No activity/full rest Full activity/no rest
In reality, no cognitive activity/full cognitive rest not practical/likely (unless asleep or comatose)
Therapeutic goal is to limit cognitive activity to a level that is tolerable, and does not exacerbate or cause the re-emergence of symptoms
Cognitive Management

33. 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.

37. Manage exertional activity, safety
Purpose of Care Plan
Guide recovery
Educate
Manage exertional activity, safety

38. Return to School

39. Return to Sports

40. Summary
Concussions can have a significant effect on the injured student’s school learning
School learning can potentially have a significant effect on recovery from concussion
Schools and school personnel play an important role in assisting the student with concussion.
Understanding and monitoring the student’s symptoms is critically important

41. Summary
Assisting the symptomatic student by reducing demands – physical and cognitive
Gradual increase in academic demands as symptoms reduce
Return to sports participation, PE, or any other risk activity requires clearance from a health care professional with training in concussion evaluation and management 15

42. Q & A

44. Questions for Schools to Ask and Prepare for
When a student is identified with a concussion, what is your response? High school, middle school, elementary school
What/ who is the team?
Who does the parent contact?
Who will connect with the teaching team?
Method to disseminate student needs with accommodations/ strategies
Who will do what?
What will you do?
How will you monitor the moving target of recovery, and adapt the accommodations as needed (i.e., this is not a black & white situation)
What is program for in-servicing teachers about concussion and its effects?

45. Support / Accommodations Procedures
Managing expectations for school demands in a student that is there in school “looking OK”
When does a student stay home, when does a student return to school (criteria for partial vs full day)
How are you monitoring recovery across the day and across the week (hint – use a sx monitoring tool)
Where/ how will you provide key accommodations?
Rest breaks
Managing tests, Assignments
Grading

46. 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.

47. 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.

48. What can I do to prepare for a concussion?
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.

49. 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.

52. Small Group Work

53. Small Group Work

54. Small Group Work

55. Concussion/ mTBI CDC 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

56. Educational Materials
Coaches, Parents, Student-athletes
Video Education:
Fact Sheets
Clipboard stickers

57. Public Awareness & Education

58. Video Education Coaches, Parents, Athletes
.                             
USA Football
NAN-NATA w NFL/NHL
Raising Concussion Awareness Educational DVD, "Concussions in Football (Hockey): Signs, Symptoms and Playing  Safe"
Play Smart: Understanding Sports Concussion
ACTive: Free Concussion Training for Sports Coaches

59. Concussion Clipboard

60. Electronic Clipboard

61. Coach/ Parent Electronic Clipboard

63. Using Technology to Assist Concussion Symptom Management

66. Alert: Your symptoms are worsening. Time for a rest break.
9:30am
Alert: Your symptoms are worsening. Time for a rest break.