Returning Children to Play &
School Following Concussion:
What you need to Know
Seattle Pacific University
Educational Series
February 3, 2015
Chris Ladish, PhD
Pediatric Neuropsychology
Mary Bridge Pediatric
Psychology & Psychiatry Service
1220 Division Avenue
Tacoma, WA 98403
(253) 403-4437, #2
http://www.multicare.org/marybridge/pediatricpsychology-psychiatry-3
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Discuss the physical, cognitive and
emotional symptoms of concussion
Discuss the educational implications of
concussion symptoms
Understand risk factors in prolonged
concussion recovery
Assist in the development of
appropriate physical, educational and
cognitive recommendations in the
return to learn and return to play
decision-making process
Ding
 Got his/her bell rung
 Saw Stars
 Just a Concussion

3.9 million activity/sports related
concussions per year (CDC)
 Falls, accidents and assault
 Media attention- professional sports,
legislation

 Nearly all states now have legislation
regarding sports concussions
 Washington was the first state to have such a
law
No athlete may return to sports if concussion
suspected
Further evaluation by licensed
professional
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Complex pathophysiological process
effecting the brain induced by traumatic
biomechanical forces.
May be caused by direct blow to head, face
or neck, or elsewhere on body with “impulsive
forces” transmitted to head.
Typically involves rapid onset of short-lived
impairment of neurological function that
resolves spontaneously.
Clinical symptoms largely reflect
functional disturbance rather than
structural injury.
 Results in graded set of clinical symptoms
that may or may not involve LOC.
 No abnormality evident on standard
neuroimaging.

PECARN
CT scan rate
Traumatic Brain Injury
ciTBI
Neurosurgical intervention
35.3%
5.2%
0.9%
0.1%
8
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Removal from field if concussion sustained
SCAT3 work group developed to improve
SCAT2
Validating SCAT for pediatric pts < 8 yo
Evolving condition, reassessments needed
“Bell ringers” = transient dysfunction of
neurological function (mgmt ???)
Injury2 days rest (> 10 days possibly
harmful)graded exercise even if sxs persist
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Physical
Cognitive
Emotional
Sleep
headache
 nausea/vomiting
 imbalance (ataxia), motor problems
 excessive drowsiness, fatigue
 photosensitivity
 auditory sensitivity
 numbness, tingling
 blurry or double vision (diploplia)

Intelligence
 General language functioning
 Knowledge base (long term memory)
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Awareness/Orientation
Attention
Mental Flexibility
Working Memory
Executive Functioning
Processing Speed
Reaction Time

Core deficits seen in concussion have
functional effect on other skills
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Trends may be subtle but significant

Day to day work, play, relationships and
life impacted by key challenge areas.
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Disinhibition
Emotional Lability
Irritability/Reactivity
Anxiety
Depression
Frustration
Hopelessness
Downplaying
impact
Confusion, disorientation
 Retro/anterograde amnesia
 Headache
 Nausea, vomiting
 Motor weakness, incoordination
 Dizziness, imbalance
 Sensory sensitivity (light, sound)
 Fatigue, increased need for sleep

Decreased processing speed
 Short-term memory impairment
 Difficulty retaining new information
 Irritability, depression, anxiety
 Fatigue, sleep disturbance
 “Foggy” feeling
 Frustration

High risk age groups:
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Children aged 0 to 4 years

Adolescents 15 to 19 years

TBI rates higher for females > males in
similar sports
› Girls 1.7/10,000 AE > Boys 1.0/10,000

Boys 0 to 4 years = highest rates
of TBI-related ED visits,
hospitalizations,
and deaths
Football:
47.1%
 Girls’ soccer:
8.2%
 Boys’ wrestling: 5.8%
 Girls’ basketball: 5.5%

Marar M, McIlVain NM, Fields SK, Comstock RD. Epidemiology of
Concussions Among United States High School Athletes in 20 Sports.
American Journal of Sports Medicine; 2012, Jan 27 (Epub ahead of print).

Player to player contact: 70.3% of
incidents
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Player to playing surface: 17.2%
Marar M, McIlVain NM, Fields SK, Comstock RD. Epidemiology of
Concussions Among United States High School Athletes in 20 Sports.
American Journal of Sports Medicine; 2012, Jan 27 (Epub ahead of print).
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22% of all hockey injuries are concussion
Marar M, McIlVain NM, Fields SK, Comstock RD. Epidemiology of
Concussions Among United States High School Athletes in 20 Sports.
American Journal of Sports Medicine; 2012, Jan 27 (Epub ahead of print).
Struck By/Against Events

Includes colliding with
a moving or
stationary object, as
in sports

Cause of 25% of TBI’s
in children 0-14 years
Broglio, Univ. of Michigan, 2010
study
cohort
linear acceleration
Pellman
Professional
(2003)
(75% injury risk)
98g
Guskiewicz
Collegiate
(2007)
(mean of 13 concussions)
Broglio
High school
(2010)
(CART of 13 concussions)
102.8g
96.1g
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Metabolic Cascade
(hours to days)
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Developing brain
(neuroplasticity vs. increased
vulnerability)
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Overuse
(implications to exertion)
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Neuroanatomical
involvement
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Neuroplasticity: younger brains are still
developing and thus are more resilient to
trauma due to brain’s ability to form alternate
neural connections for function.
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Vulnerability: higher mortality rate seen with TBI
in younger children likely due to higher rate of
cerebral edema.
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Animal models support both factors.
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Unilateral cortical lesions.
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Recovery of function associated with increased dendritic
growth within uninjured cortex dependent upon use of the
intact forelimb.
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Restraint of uninjured forelimb with overuse of the injured
limb results in failed dentritic enhancement, increased
lesion size in injured cortex, and longer behavioral deficits.
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Some mitigation with delayed use: no lesion increase but
functional recovery still delayed.
Considerations Regarding
Resumption of ‘Activity’
(Silverberg, N. and Iverson, G., 2012. Jnl Head Trauma Rehab
Thomas, D., Apps, J., Hoffmann, R., McCrea, M., Hammeke, T. 2015. Pediatrics)
Complete rest beyond 3 days probably
not helpful in most cases (not all)
 Gradual resumption of preinjury, non
impact activities should begin as soon
as tolerated
 Supervised exercise of benefit to patients
with persistent symptoms both physically
and emotionally
 Caution re early restrictions establishing a
“mindset” for recovery expectations
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Physical symptoms and altered mental
status usually first noted
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Physical symptoms often improve before
cognitive.
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Cognitive symptoms may worsen during
first 48-72 hours due to cellular and
metabolic changes.
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Majority of pediatric cases with mild
injury are back to baseline at ???
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Physical
Cognitive
Emotional
Sleep
Acute Phase
(Injury – 3 days)
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Post Acute
(3 days-3 months)
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Prolonged (PPCS)
(> 3 months)
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Activity restriction determined by extent
of current injury, history of previous
injuries, functional presentation of
patient
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Ongoing evaluation to inform treatment
needs and monitor recovery trends
Rest
 Reduction of Stimulation
 Reduction of Exertion
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› Physical, emotional & cognitive
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Modified Expectations
› Assessment of rehab needs
› Education re care provider roles
› Brief directed cognitive assessment
 (EF, working memory, stim tolerance,
endurance)
› Set and monitor activity restrictions
› Support adjustment to activity limitations
› Facilitate return to activity (and stimulation)
› Reintegration to school
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What is Head Injury

Recovery Course
and What to Expect
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Symptoms &
Management
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Resources
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Cognitive Rest
Limit stimulation
Time off from school
Reduction in work
Educational
Accommodations
(504,IEP)
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Don’t panic
10-20% of pediatric concussions can
take 3 weeks or more
HS athletes take twice as long as
college/professional athletes to recover
(10-14 days vs. 3-7 days)
Younger kids take longer
They will get better, even if it takes a
while
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Psychosocial stress
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Previous history
 Bright kids
 Concussions
 Anxiety
 Headaches
 Depression
 Family hx of HA
 Chronic medical
illness
 Difficulties at home
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Learning disabilities
 ADHD
 Dyslexia
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Sleep problems
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Prior high standard of academic
performance
“Overnight” changes to functioning
More time needed for homework/studying
Frustration with current deficits
Increased cognitive exertion exacerbates
symptoms
Teachers/peers not aware b/c student at
grade level
Student feels unsupported/deficits minimized
At risk for depression/anxiety/pessimism re:
future
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Headache- most common
 Makes concentration difficult
 Avoid triggers (e.g. lights, noises, subjects (math,
high level science, foreign language)
 Is this present at baseline
 Limit NSAIDs
 Focus on sleep
 Riboflavin, magnesium, fish oil
 Occasionally consider amitriptyline or neuro
referral
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Dizziness/lightheadedness
 Vestibular system/sensory organization
problem
 Usually worsened by quick movements, video or
hallways
 Vestibular therapy
 Lightheaded- sense that they may pass out
with position change
 More problematic because of limited cerebral
perfusion
 Light aerobic activity or exercise in lying position
 Careful position changes
 Nausea
 Zofran
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Neck strain- often present with head
injury
 Sometime can drive symptoms, even cause
dizziness
 Treat with heat, PT, massage, even muscle
relaxers at times
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Sleep disturbance – makes most
symptoms worse
 Can’t fall asleep, wake up at night,
excessive napping
 Affects ability to attend and focus, new
learning is difficult
 If you don’t sleep you can’t do anything
well, even without a head injury
 Treat aggressively- sleep hygiene, melatonin,
sometimes other meds
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Mental health
 Head injuries have a way of unmasking underlying
problems
 Depression, anxiety, conversion disorder
 Concussed kids lose coping strategies (high
performance in sports or school, exercise for stress
relief, social interaction, video games)
 Address and normalize what they are going through
 Psychology referral when necessary
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Difficulty with concentration and short
term memory
 Often most persistent symptoms
 School accommodations
 Patience (often take months, reassuring
when there is a trend toward improvement)
 Often pre-existing learning issues
 Stimulants on occasion
 Cognitive rehabilitation
 Neuropsychology referral
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Need for education re management
Presence of preinjury risk factors: learning,
attention, psychosocial
Cognitive challenges
School issues
Change in behavior, mood, personality
Undue parental, coach pressure re RTP
Need for cognitive clearance for RTP
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Collaborative effort between student, parents,
educators, coaches, and health care
professionals
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Careful plan to facilitate transition/reduce risk of
failure
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Focus on individual student needs (current
functional deficits, pre-existing risk factors,
academic status)
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Set clear goals with student
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Close monitoring and feedback to
student/parents
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Adjust plan with recovery
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Modifying the school schedule (reduced
endurance, fatigue, processing)
› Reduced school day/late arrival
› More frequent breaks in school day
› Additional study period/study skills class
› Drop classes with significant new learning:
foreign language, higher-level math and
science classes (e.g., calculus, physics,
chemistry)
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Safety precautions
(increased vulnerability,
Increased distractibility)
› No PE
› No activities in gym or on playground
› No woodshop, auto mechanics, any class
with risk of injury
› Early dismissal from class to avoid crowded
hallways
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Environmental accommodations
(inattention, sensory sensitivity)
› Preferential seating
› Reduction of distractions
› Testing in a quiet environment
› Avoid noisy environments (e.g., cafeteria,
assemblies)
› Rest periods in nurse’s office if
headaches/fatigue
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Adjusting requirements/grading
(reduced cognitive resource, fatigue,
slowed processing)
› Forgive missed work
› Grades based on completed/representative
work
› “Freeze” grades
› Assign incompletes
› Use pass/fail option
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Modifying assignments (processing,
attention, memory, learning)
› Decrease work load (e.g., length of spelling/
vocabulary word list, even or odd math
problems)
› Use aides: calculators, computers, “cheat
sheets”
› Assign peer note-taker
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Modifying tests (processing
speed, retrieval)
› Untimed testing option
› Open book, “cheat sheets,” note
cards
› Recognition tests (multiple-choice,
T/F)
› Assistance with first few
steps/problems
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Support for new learning
› Review of previously learned academics
› New material/concepts presented in context of
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familiar or already-acquired knowledge
New material/concepts broken down into small
chunks
Multimodal instruction
Repeated exposure to novel information
Frequent review of new material
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Implement schedules, calendars, to do lists
Maintain pictures/lists of assignments
Break down large tasks
Frequent reinforcement
Provide concrete time limits and
communicate them directly (verbal, written,
timer, task-based)
Frequent feedback, and redirection if
needed
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Approximately 24 hours (or longer) in between each step
If symptoms, stop activity, rest until symptom-free 24 hours, return to previous step
If symptoms increase, seek medical attention
1.
Light General Conditioning Exercises (Goal: Increase HR)
2.
Moderate General Conditioning and Sport Specific Skill Work
Individually (Goal: Add Movement, individual skill work)
3.
Heavy General conditioning, skill work individually and with
teammate. NO CONTACT (Goal: Add Movement, teammate skill
work)
4.
Heavy General conditioning, skill work, and team drills. No live
scrimmages. VERY LIGHT CONTACT. (Goal: Team skill work, light
static contact)
5.
Full Team Practice with Body Contact
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Quick to administer
Administration “standardized”
Randomized forms
Serial tracking of recovery with less chance
for practice effect
Available to non-NP providers and can be
given in schools and office.
Some higher measurement sensitivity.

What are we truly measuring?
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Does less data lead to less ability to generalize
findings?
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Response type constrained by computer
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Requires careful oversight of administration.

Athletes “dumbing down” baseline screens.
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Increased risk for another TBI
with more severe symptom
presentation
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Cumulative effects of
repeated injuries
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Potential catastrophic or
fatal outcomes of repeated
injuries within short time
period
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Increased risk of
sustaining concussion
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Longer recovery period
from concussion
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Rapid early recovery
from moderate/severe
TBI but…
Increased risk for
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Alzheimer’s disease
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Parkinson’s disease
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Other brain disorders associated w/
aging
http://www.cdc.gov/concussion
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Concussion is a multifaceted and complex
functional injury.
Neurocognitive symptoms may be present
which are not immediately evident during the
first few days of evaluation.
Recovery course from concussion is variable
with outcomes determined by previous risk
factors, injury severity, past concussions and
management.
Caution is warranted with all concussions and
return to activity remains a medical decision
which should be informed by ongoing
attention to physical, cognitive, and emotional
factors.