1. Matthew Hall, D.O. Assistant Professor, Sports Medicine Director, UConn Sports Concussion Program Medical Director, UConn Club Sports UConn Health, Dept. of Orthopedics New England Musculoskeletal Institute

2. Objectives  Recent evidence on cognitive rest in treatment of concussions.  Review “best practices” and guidelines regarding return to learn.  Discuss school adjustments and accommodations for students with concussion

3. Return to Learning  “Majority of the focus on concussions has been centered on diagnosis, education of key stakeholders regarding the problem, and the timing of safe return to play” (Halstead et al.)

4.  No standardized guidelines, guidelines based on “expert opinion”  Determined by the health care provider  Individualized treatment plan Return to Learn

5.  No consensus guidelines  Neurocognitive deficits may persistent despite being asymptomatic  Students with increased symptoms with school may require : ○ Reduced work load ○ Extended test-taking time ○ Days off from school ○ Shortened school days

7. AAP Recommended Approach  Return to learn if able to tolerate light mental exertion for 30 minutes  Standard class/period lengths 30-45 minutes in length  Short periods of rest between classes may be necessary vs. dismissal when symptomatic

8. Cognitive Rest  Accepted practice & treatment for concussion  What is the evidence for cognitive rest as a treatment for concussion?  How much cognitive rest is enough?  How do you define cognitive rest?

9. Definition of Cognitive Rest (Moser et al.)  Time off from school  No homework  No reading  No visually stimulating activities  No exercise  No social visits  Increased rest & sleep

10. Studies on Cognitive Rest  Moser et al. Efficacy of Immediate and Delayed Cognitive Rest for Treatment of Sports-related Concussion. The Journal of Pediatrics (2012) Retrospective cohort (N = 49) Prescribed cognitive rest All had improved ImPact scores with rest Even those with prolonged symptoms still showed improvement with rest

11. Studies on Cognitive Rest  Gibson et al. The Effect of Recommending Cognitive Rest on Recovery from Sports-related Concussion. Brain Injury (2013) Retrospective chart review (N = 135) Primary outcome = duration of post-concussive symptoms Looked to see if cognitive rest was within the provider’s plan in the medical record No associated between length of symptoms and whether or not cognitive rest was prescribed

12. Studies on Cognitive Rest  Brown et al. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Pediatrics (2014) Prospective Cohort (N = 335) Primary outcome = duration of symptoms associated with “cognitive activity-days” Cognitive activity-days = average cognitive activity level x days between visits Patients self-reports their cognitive activity level

13. Brown et al. Cognitive Scale

14. Duration of symptoms by quartile of cognitive activity-days. Brown N J et al. Pediatrics 2014;133:e299-e304 ©2014 by American Academy of Pediatrics

15. How to “prescribe” cognitive rest?  Relative cognitive rest, not “bubble” therapy  Avoid noisy public locations i.e. restaurants  Limit screen time  No headphones  Short periods of an activity i.e. reading Start with less strenuous i.e. magazine and not AP homework  Symptoms increasing? Stop, rest, and remember the threshold

16. School Considerations  Consider each student-athletes needs  Include detailed school note regarding accommodations and adjustments  Difficult cases may require discussion with school or more of a multi- disciplinary approach

19. Team Approach  Communication between school, physician, and athletic trainer Challenge! Particularly in the office setting… Need to abide by FERPA & HIPAA  Multi-disciplinary team necessary for prolonged symptoms and post- concussive syndrome

20. Adjustments vs. Accommodations (Halstead et al.)  “Adjustments” Initial recovery period, first 1-3 weeks No formal change to student school environment  “Accommodations” Symptoms > 3 weeks Standardized test changes, extended time for tests & assignments, schedule changes Formalized with a 504 plan

21. 504 Plan  From Section 504 of Rehabilitation Act and Americans with Disability Act  Students who require accommodations because of a medical diagnosis but do not qualify for an IEP  Can be requested by provider

22. Individualized Education Plan (IEP)  Allows for “modification” to students education and dictates what services should be provided to the student  Protected under the Individuals with Disabilities Education Act  Testing to determine if student requires and IEP can be requested by the family or the school

23. History Considerations  Learning disability?  Multiple concussions?  Concussion with prolonged symptoms?  Immediately removed from sport?  Depression or anxiety? Mood Disorder?  Migraines?  Family stressors?  School pressures or testing?

24. My Practice  Primarily high school age  Out of school for 3-4 days, using the calendar to my advantage  Try to integrate back to school as soon as possible  Detailed school note  Start as half days if can tolerate, early on more about getting them back to their routine  Progress to full days as able to tolerate  Follow-ups early and often

25. What can we do better?  Communication with schools: School nurses and/or ATC to help monitor and manage symptoms Counselor or psychologist to help the accommodations and transitioning to full time school Education and awareness for providers seeing concussions, better guidelines to aid in return to learn Individualized “return to learn” plan

26. References  Harmon KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring SA,Kutcher JS, Pana A, Putukian M, Roberts WO. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013 Jan;47(1):15-26.  Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K; Council on Sports Medicine and Fitness; Council on School Health. Returning to learning following a concussion. Pediatrics. 2013 Nov;132(5):948-57.  Gibson S, Nigrovic LE, O'Brien M, Meehan WP 3rd. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj. 2013;27(7-8):839-42.  Moser RS, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. J Pediatr. 2012 Nov;161(5):922-6.  Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP 3rd. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014 Feb;133(2):e299-304.  Majerske CW, Mihalik JP, Ren D, Collins MW, Reddy CC, Lovell MR, Wagner AK. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008 May- Jun;43(3):265-74.