2. No one worried in the good old days about non-athletes Child abuse Domestic violence “Extreme sports”

3. Collins, et al. Neurosurgery 58:275-286, 2006

4.  May not be the athlete- could have happened outside of school, in gym class, slip and fall, etc  Symptoms may be delayed or not manifest until brain is cognitively stressed  Student complains of symptoms

8. Consistent message to the Student (and parents) real The injury is real ◦ Waiting for a full recovery is critical. ◦ Prolonged recovery or even catastrophic injury by returning to activity too soon ◦ Academic accommodations can be provided during recovery

9. COGNITIVE Fogginess Concentration Memory deficits Cognitive fatigue MOOD DISRUPTION Irritability Sadness Anxiety SLEEP DYSREGULATION Falling asleep Fragmented sleep Too much/too little sleep SOMATIC Headaches Dizziness Light/noise sensitivity Tinnitus Adapted from Camiolo Reddy, Collins & Gioia, 2008

10. ◦ Wake up fatigued ◦ Develop headaches sitting in class ◦ Can’t fully grasp class material ◦ Feel worse as the day wears on ◦ Bothered by light/sound at school ◦ Feel more exhausted after school ◦ More symptomatic trying to do homework ◦ Upset and worried they are falling behind ◦ Go to bed feeling worse

11. ◦ Improve with rest …  Physical/sports exertion  Mental exertion  Sustained attention in class and during school day  Reading  Homework  Tests/quizzes/standardized testing  Computer vs iPad use

12.  Higher number of concussions/mTBI  mTBIs occurring too close in time ◦ Re-injury prior to full recovery  Pre-existing learning disability or migraine issues Physical exertion OR cognitive stress can cause symptom flare-ups & prolong recovery.

13. ◦ Temporary? ◦ Can be a PERMANENT problem ◦ Improves more quickly with proper management ◦ Complete recovery typically expected

14.  Individualization  Innovation  Integration/Team work ◦ RN – ATC ◦ Guidance – Teachers ◦ Psychologists – Social Workers ◦ Parents  Fluid situation that will change over time

15.  Excused absence from classes  Time out of school/complete rest to start?  Partial attendance as able  Morning fatigue/poor sleep > arrive late  Afternoon fatigue in school > leave early  Selective attendance?  Core classes vs. electives?  Avoid classes that are too challenging?

16.  Rest periods during the school day o School nurse’s office o Rest before symptoms become too intense o Take Tylenol/Advil, etc. as recommended by doctor o Return to classes if feeling better o Early dismissal if rest does not help sx

17.  Extension of assignment deadlines! ◦ Homework, papers, projects ◦ According to student’s capacity ◦ Removes major source of pressure ◦ Allows student to prioritize sleep & rest!

18.  Excuse from some assignments ? ◦ More common in lower grades ◦ Less catch-up to do during/after recovery ◦ Consolidate work into more manageable units ◦ Allow independent work with alternative ways to submit

19.  Postpone exams ◦ Until student is able to prepare and symptoms are under better control ◦ Avoid high stakes testing (e.g. AP exams, SAT) while symptomatic ◦ Extended time (x1.5 or x2) until recovered ◦ Spring injuries - wait until summer to complete course work and exams? ◦ Evaluate true necessity of exam/quiz for student assessment- ? Alternative format

20.  Light/noise sensitivity ◦ Excuse from assemblies ◦ Able to eat lunch away from cafeteria ◦ Cap and/or sunglasses for light sensitivity ◦ Avoid fluorescent lights, windows ◦ Limit iPod, TV, computer exposure based on symptoms ◦ Limit texting ◦ Adapt music to what is comfortable

21.  NO sports, gym, music/theater/dance ◦ Use time for rest & homework ◦ Short practice visits to stay connected to team ◦ DO NOT ride bus to away games with team ◦ DO NOT sit on bench during games  In stands with family if symptoms allow ◦ Prom

22.  Limit other forms of physical exertion  Heavy backpacks  Climbing stairs  Walking home from school/bus stop  Caring for large animals, or walking the dog  Operating heavy equipment  DRIVING ◦ Be aware of impaired judgement/ability to react to dangerous situations

23.  Athletic Trainer  Monitoring of symptoms  Periodic neurocognitive testing  School Nurse  Daily clinical evaluations  Rest & recovery area  Medication  Guidance counselor  Coordinates academic accommodations

24.  Teachers  Adjust work according to changing status  Reassurance  Be careful of pressure  Psychologists  Specific input for LD-ADHD students  Social Workers  Adjustment support - especially in longer recoveries

25.  Need clear team leader through whom all information flows  Hold the medical team to a standard of communication ◦ Forms to complete/care plan to communicate ◦ Feedback to medical re. symptoms, performance  Have clear policies in place to deal with parents who do shop around, “I’ll sign and take responsibility”  Policies in place for 504 Plan for mTBI ◦ Academics must have priority

26.  Pressure from coaches (any kind) ◦ “be there to support the team” “faking it”  Family ◦ “when I played football” “we have a lot invested” ◦ “just trying to get out of…” “my uncle is an EMT…”  ?Friends and/or teammates ◦ “faking it” “we lost because you were out” ◦ Cyber bullying ◦ Loss of social life if witheld from group activity

27.  www.cdc.gov/concussion  www.impacttest.com www.impacttest.com  www.sportsconcussion.net www.sportsconcussion.net  www.sportslegacy.org