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
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
• “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
Student Athlete
Multidisciplinary Team to Facilitate “Return to Learning”
Pediatrics Vol. 132, Number 5, Nov. 2013
School Team - Physical
School Team – Academic
Coaches
Athletic Trainers
School Nurse
PE Teacher
Teachers
Nurse
Counselor
Administrators
School Psychologist
Education &
Collaboration
Supporting
Students
Family Team
Parents
Student
Grandparents
Peers
Teammates
Family Friends
Medical Team
Emergency Department
Primary Care Provider/Pediatrician
Concussion Specialist
Neuropsychologist
Common Symptoms
PECS
• Physical
• Emotional
• Cognitive
• Sleep
Physical
•
•
•
•
•
•
•
•
•
Headache
Nausea
Vomiting
Balance problems
Dizziness
Visual problems
Fatigue
Sensitivity to light
Sensitivity to noise
Emotional
•
•
•
•
Irritability
Sadness
More emotional
Nervousness
Cognitive
•
•
•
•
Feeling mentally foggy
Slowed thinking
Difficulty concentrating
Difficulty remembering
Sleep
Drowsiness
Sleeping less than usual
Sleeping more than usual
Trouble falling asleep
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
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
Balancing
Medical Needs & Academic Needs
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. 2012.
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 (2030 minutes at a time).
Increase cognitive stamina by
repetition of short periods of selfpaced 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
Increase to a full day of school.
Accommodations decrease as
cognitive stamina improves.
Introduce testing, catch up with
essential work.
Full return to school; may commence
Return-to-Play protocol.
Gradual reintegration into school
Resumption of full cognitive
workload
Source: Master, Gioia, Leddy, Grady
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.
Helping Students Recover from a Concussion: Classroom Tips for Teachers
CDC concussion resources
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
When is it time to consider more structured accommodations?
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
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.
Multidisciplinary Team to Facilitate “Return to Learning”
Pediatrics Vol. 132, Number 5, Nov. 2013
School Team - Physical
School Team – Academic
Coaches
Athletic Trainers
School Nurse
PE Teacher
Teachers
Nurse
Counselor
Administrators
School Psychologist
Education &
Collaboration
Supporting
Students
Family Team
Parents
Student
Grandparents
Peers
Teammates
Family Friends
Medical Team
Emergency Department
Primary Care Provider/Pediatrician
Concussion Specialist
Neuropsychologist
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?
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.
Consistent Messaging Regarding Return to Learn
Collegiate Level Athletes
http://brain101.orcasinc.com/
Kristi Pardue M.S.,CCC-SLP,CBIS
Manager, St. Luke’s Sports Medicine Concussion Clinic
p: (208) 381-2665
parduek@slhs.org