Cathy O’Connor AT, MD, FACS
Goodall Hospital
Maine Concussion Management Initiative





Educate about Mild Traumatic Brain Injury
How to identify a student with potential injury
How brain injury affects academic performance
Understand the need for academic
accommodations during MTBI recovery.
Review more commonly used academic
accommodations.
No spare brains
available

Long lasting
consequences if not
managed properly in
kids

Education and patience
is the key

No spare brains
available
Long lasting
consequences if not
managed properly in
kids
Education and
patience is the key



Mild Traumatic Brain Injury (MTBI)
Same injury and mechanism as what we see in
military veterans who are victims of IEDs
Throw out all previous assumptions about
“concussion”- new game
Brain Metabolism is Related to Recovery
◊ Over 200 High School Athletes Studied using fMRI
◊ Hyperactivation predicts CLINICAL recovery time
◊ Resolution of hyperactivation correlates with recovery
Collins, et al. Neurosurgery 58:275-286, 2006
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.



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 not able to focus, pay attention, fails quiz
or test, odd answer to verbal question, appears to
have problem with lights
Physical
 Headaches
 Fatigue/tiredness
 Dizziness with movement or mental
exertion
 Nausea
 Light/noise sensitivity
 Ringing in the ears
Cognitive
 Inability to focus
 Limited concentration
 Inefficient short-term memory
 Slowed thinking
 Feeling mentally “foggy”
 Poor reading comprehension
Sleep difficulties
 Trouble falling asleep
 Overnight awakening
 Oversleeping/undersleeping
 Feeling tired in the morning despite
long hours in bed
Mood disruption
 Irritability
 Sadness
 Nervousness
 Anxiety
 Depression
COGNITIVE
•Fogginess
•Concentration
•Memory deficits
•Cognitive fatigue
SLEEP
DYSREGULATION
SOMATIC
Falling asleep
Dizziness
Fragmented sleep
Light/noise sensitivity
Too much/too little sleep
Tinnitus
Headaches
MOOD
DISRUPTION
Irritability
Adapted from Camiolo
Reddy, Collins & Gioia, 2008
Sadness
Anxiety
◦ 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
 Controls for individual factors such as
LD, ADHD, medications, etc.
 Can be done in large groups with
educational seminars
 Orients athletes to concussion issues at
start of season
 Annually for injured athletes; every 2
years for those with no concussion
history
 Baseline and post injury testing
CASE 1:
KICK-OFF
RETURNER
DAY
3
6
10
13
14
Exertion
◦ Improve with rest…
 Physical/sports exertion
 Mental exertion
 Sustained attention in class and during
school day
 Reading
 Homework
 Tests/quizzes
◦ Temporary?
◦ Short-lasting?
◦ Improves more quickly with proper
management
◦ Complete recovery typically expected



Athletic Trainer
◦ Monitoring of symptoms
◦ Periodic neurocognitive testing
School Nurse
◦ Daily clinical evaluations
◦ Rest & recovery area
◦ Medication
Guidance counselor
◦ Coordinates academic accommodations
 Teachers
◦ Adjust work according to changing status
◦ Reassurance
 Psychologists
◦ Specific input for LD-ADHD students
 Social
Workers
◦ Adjustment support - especially in longer
recoveries
Consistent Message to the Student:
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

Individualization
◦ Accommodations
◦ Key staff
Innovation
 Integration/Team work

◦ RN – ATC
◦ Guidance – Teachers
◦ Psychologists – Social Workers
◦ Parents

Fluid situation that will change over time

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?

Rest periods during the school day
 School nurse’s office
 Go to rest before symptoms
become too intense
 Take Tylenol/Advil, etc. as
recommended by doctor
 Return to classes if feeling better
 Early dismissal if rest does not help

Extension of assignment deadlines!




Homework, papers, projects
According to student’s capacity
Removes major source of pressure
Allows student to prioritize sleep &
rest!

Excuse from some assignments ?
 More common in lower grades
 Less catch-up to do during/after
recovery
 Consolidate work into more
manageable units

Postponement of quizzes & tests
◦ 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

Accommodation for 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

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
◦ 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
Outermost
layer
Learn new info
Form thought
Make decisions
Memory function





Recent memory
Emotions
Concentration
Ability to learn new info
and retain it
Storage of motor
patterns and voluntary
activity
Processing of
sensory input
 Sensory
discrimination
 Body orientation

Processing
visual input
of all
Expressed behavior:
childish, irritable,
agitated
 Information retrieval
 Receptive
speech/auditory
input processing


www.cdc.gov/concussion

www.impacttestonline.com

www.sportsconcussion.net

www.sportslegacy.org