learn following concussion in management of return to
TRANSCRIPT
An interdisciplinary management of return to learn following concussion in secondary schools
LAURA WILSON, PHD, CCC-SLP, CBIST, THE UNIVERSITY OF TULSA
RACHEL HILDEBRAND, PHD, LAT, ATC, CBIS, THE UNIVERSITY OF TULSA
DAN NEWMAN, MS, LAT, ATC, UNION PUBLIC SCHOOLS
Learning Outcomes
1. Describe the role of different professionals in the management of return-to-learn
2. Identify potential changes to current return-to-play protocols to help align them with best practices
3. Recognize and address barriers to implementation of best practices related to return to learn in the secondary school setting
Disclosures
LW and RH are full-time employees of The University of Tulsa. DN is a full-time employee at Union High School. There are no other financial disclosures.
Please make sure you reference your individual state laws and practice acts before making any changes to your already established protocols.
Who are we and how did we get here?
Quick note on appropriate diagnostic assessments
Should contain a battery of examinations that include, but not limited to:
● Cognitive assessment of working memory
● Motor control evaluation● Symptom assessment
(NATA Position Statement, 2014)
Several commercial products incorporate each of these:
● SWAY● SCAT 5
Can include individual pieces:
● Rivermead Concussion Symptoms Checklist● VOMS● BESS Test● ImPACT Test
Interdisciplinary Concussion Team
Having a concussion team allows for individuals to focus within their areas of expertise
The person that needs to take the lead can be determined based on the team needs OR student needs◦ 3/4 of the time the athletic trainer is viewed as the
person who monitors the health status of the patient/client (Kasamatsu 2016)
◦ BUT…◦ 1/3 of the time the athletic trainer is viewed as the
person who progresses a patient/client academically (Kasamatsu 2016)
◦ Speech pathologists are well positioned to help meet that need
Challenges to implementation of best practices for return-to-learn Poor/absent state laws◦ MIssissippi was the last state to have
a youth concussion law at all
Unclear protocols
Limited personnel/unclear roles◦ Schools without a dedicated athletic
trainer◦ Lack of involvement by the SLP◦ Lack of training for school personnel◦ Lack of classroom teacher support◦ Coordinating all of the necessary
players
Managing non-athletes or concussions that occur outside of the school setting
Emerging evidence for specific interventions
Lack of adherence by students
Concurrent enrollment
Shared principles for early concussion management Education
Brief period of cognitive and physical rest
◦ More rest is not better (e.g., Thomas, 2015)
◦ Newer evidence suggests early (i.e., before concussion symptom resolution) light aerobic activity (in the absence of symptom exacerbation) can promote recovery (e.g., Leddy, 2016)
Serial assessment of symptoms◦ With symptom monitoring before and during increase in activity (avoiding symptom
exacerbation)
Advancing activity slowly and systematically (e.g. Halstead, 2018)◦ No longer do we recommend NO physical activity◦ No longer do we recommend NO electronic devices◦ No longer do we recommend keeping children out of school for a long time
5 key components of the return to learn portion of plan1. The formation of an interdisciplinary team with documented expertise in brain injuries, including concussion
2. Professional development of all school-based personnel◦ Examples: causes, signs/symptoms, effects on learning, risks of early resumption of activities, types of
accommodations, role of team members, tracking recovery, handling atypical recovery, communication
3. Screening/identification, serial assessment, and developmental surveillance
4. Accommodations and interventions◦ Return to learn should follow a systematic, graduated process (like in return to play)◦ Return to learn should be completed BEFORE return to play protocol...but that doesn't mean NO physical
activity◦ Accommodations/adjustments should be targeted to specific presentation of symptoms by the student◦ Concussion education is an important component of recovery◦ Protocols should consider triggers for moving to more long-term management (e.g., a 504 plan)
5. Communication◦ Family and school, school and medical, within-school
Newlin & Hooper, 2015 (citing Gioia and colleagues)
Practical considerations when writing or amending a protocol
Know your state's law and your state association’s policy◦ https://www.misshsaa.com/2021/07/14/mhs
aa-concussion-policy/
Make sure what you can deliver on what you write
Be clear with steps that are triggered (e.g., communication with teachers), but allow for individualization (e.g., accommodations)
Know your resources and who is on your concussion management team
UNION HIGH SCHOOL
Concussion protocol components- RTL is just one piece!
GENERAL MANAGEMENT Definitions
Signs and symptoms
Recovery trajectories
Education requirements for coaches, students, parents, etc
Baseline testing
POST-ACUTE MANAGEMENT Who can clear athletes for resumption of activity
Return to learn steps
Return to play steps
ACUTE MANAGEMENT Sideline assessment
Policies for when to seek additional medical intervention
No same day return to play
Dear Teachers, Administrators, and Staff, On DATE, during a JV football game Joe Smith sustained a head injury. He was evaluated on DATE and again DATE. After evaluation, Joe has been diagnosed with a concussion and placed in our concussion protocol. As per our protocol, Joe will be held out of school thru DATE. Joe will be evaluated on a daily basis including the days he is away to from school to better monitor his progress and symptoms.
Upon Joe’s return to the classroom, he may need some academic accommodations as his symptoms may not allow him to handle a full all day academic load. I have attached a copy of our concussion protocol for you to review and it also contains some examples of accommodations he may warrant. I want to thank each of you for your assistance and cooperation with Joe as he recovers. If you have any questions or concerns please do not hesitate to contact me. I will update you when Joe returns and throughout his progress.
UHS: Return to Learn language•It is important that the SA is not completely isolated during recovery; he or she may do mental activity as tolerated such as watching TV, texting, or talking on the phone, etc. This should be encouraged to be kept to a minimum.
•Once the student-athlete begins to improve and does not have return of symptoms with mental activity, he or she may begin the step-wise progress for Return-to-Learn Protocol. Each program will fit the individual needs of the student-athlete.
◦ Note: Progression is individual. All concussions are different. Student-athletes may start at any step (also modify steps as necessary) depending on symptoms and remain at the step as long as needed. Return to previous step or modify step if symptoms worsen.
•The return-to-learn progression will be monitored and guided by the athletic trainer and academic counselor, and principal.
Referrals It is important to note that most concussion will resolve within 7-14 days and not all will need outside referral or treatment. Initial evaluation – develop plan
◦ Decided if athlete needs to be homebound◦ Upon return to school – initiate RTL plan
Daily Monitoring◦ Continuous evaluation of symptoms◦ Pending on severity and days from initial injury referral may be necessary
Who do you refer to within the Concussion Management Team◦ Team physician Neuropsych◦ Physical therapy SLP◦ Neurologist OT
When referring out it is important that all members of the concussion team are open with communication with all parties. The AT is the linchpin in this process. There is continuous monitoring until athlete has return to full classroom activity and physical activity.
Providing SLP services to those with persistent concerns
SLP interventions for students with persistent concerns should be individualized and could include:
Direct attention training Metacognitive strategy instruction Training of assistive technology for cognition Psychoeducational supports Strategies for managing of somatic symptoms
(E.g. Sohlberg & Ledbetter, 2016, Wright et al., 2020)
Professional development for school personnel: Training Resources https://www.cdc.gov/headsup/schools/index.html
◦ Information for nurses, other school professionals, and parents
https://www.cbirt.org/concussion/teachers◦ Information for teachers, told from the perspective of a person with a brain injury
https://nfhslearn.com◦ Free training course on concussion in sports
https://injury.research.chop.edu/concussion-research-CIRP/concussion-care-and-head-injury-prevention-education#.XJKVMWUgf-0
◦ Infographics, short videos, recommendations related to return to learn
https://www.nationwidechildrens.org/specialties/concussion-clinic/concussion-toolkit◦ Concussion toolkits- one geared at school personnel, one at administrators