concussions and the road back to the classroom gerard a. gioia, ph.d. pediatric neuropsychologist...
TRANSCRIPT
Concussions and the Road Back to the Classroom
Gerard A. Gioia, Ph.D.Gerard A. Gioia, Ph.D.Pediatric NeuropsychologistPediatric Neuropsychologist
Chief, Division of Pediatric NeuropsychologyChief, Division of Pediatric NeuropsychologyDirector, Safe Concussion Outcome, Director, Safe Concussion Outcome,
Recovery & Education (SCORE) ProgramRecovery & Education (SCORE) ProgramChildren’s National Medical Center Children’s National Medical Center
Washington, DCWashington, DC
Disclosure Test AuthorTest Author
Behavior Rating Inventory of Executive Function Behavior Rating Inventory of Executive Function (BRIEF) Psychological Assessment Resources, Inc.(BRIEF) Psychological Assessment Resources, Inc.
Tasks of Executive Control (TEC)Tasks of Executive Control (TEC) Pediatric Immediate Post-Concussion Assessment Pediatric Immediate Post-Concussion Assessment
and Cognitive Testing (Pediatric ImPACT)and Cognitive Testing (Pediatric ImPACT) Acute Concussion Evaluation (ACE)Acute Concussion Evaluation (ACE) Concussion Recognition & Response AppConcussion Recognition & Response App Concussion Assessment & Response (CARE) AppConcussion Assessment & Response (CARE) App
Plan for the Day Concussion 101: What is it?Concussion 101: What is it? Effects of Concussion on School Learning & Performance Effects of Concussion on School Learning & Performance Effects of School Learning & Performance on Concussion Effects of School Learning & Performance on Concussion
RecoveryRecovery Strategies for Supporting RecoveryStrategies for Supporting Recovery Q&AQ&A
BreakBreak Small Groups: Examining your concussion policies & Small Groups: Examining your concussion policies &
procedures, developing/ expanding procedures, developing/ expanding Large Group: Discussion of policies & procedures; Q&ALarge Group: Discussion of policies & procedures; Q&A
“Your Brain is Your Future”
(and the source of your parents’ retirement…)(and the source of your parents’ retirement…)
A concussion is a brain injury
Brain injuries threaten the Child’s future
Concussion Care for Kids: It’s a TEAM Sport!
Who’s on the Team?
Child/ Teen(Student, Athlete,
Son/Daughter,Friend)
Family
Medical Systems
Pre-Hospital (EMS) Emergency
Urgent Primary Care
Specialty Care
School
Four Corners Approach to
Concussion Care
Administrators Athletic/ Recreational
AdministratorsCoachesOfficialsParents
Teammates
Teachers
School Nurse/ Counselor
Psychologist
Certified Athletic Trainer
Certified Athletic Trainer
Certified Athletic Trainer
What is a Concussion? A concussion is an A concussion is an injury to the braininjury to the brain
caused by a direct blow to the head, face, caused by a direct blow to the head, face, neck or elsewhere on the body that causes neck or elsewhere on the body that causes the head and brain to move rapidly back the head and brain to move rapidly back and forth. and forth.
A concussion results in the onset of A concussion results in the onset of impaired brain functionimpaired brain function, producing a set of , producing a set of clinical clinical signs and symptomssigns and symptoms (physical, (physical, cognitive, emotional, sleep) that may or cognitive, emotional, sleep) that may or may not involve loss of consciousness. may not involve loss of consciousness.
What is a Concussion? Recovery of the clinical and cognitive Recovery of the clinical and cognitive
symptoms symptoms typicallytypically follows a sequential follows a sequential course over a period of days to weeks.course over a period of days to weeks.
In a small percentage of cases, post-In a small percentage of cases, post-concussive symptoms concussive symptoms may be prolongedmay be prolonged for for months or longer. months or longer.
Typically, no abnormality on standard Typically, no abnormality on standard structural neuroimaging studies (CT, MRI) structural neuroimaging studies (CT, MRI) is seen in a concussion.is seen in a concussion.
Effects of Concussive Forces on the Brain
Typically, the “software” of the brain is Typically, the “software” of the brain is affected affected Neurometabolic/ neurochemical processesNeurometabolic/ neurochemical processes PhysiologicalPhysiological
Not the “hardware” Not the “hardware” Structure Structure
Neurometabolic Cascade FollowingTraumatic Brain Injury
2 6 12 20 30 6 24 3 6 10
minutes hours days
500
400
300
200
0
50
100
% o
f nor
mal K+
Glutamate
Glucose
Cerebral Blood Flow
Calcium
UCLA Brain Injury Research Center
(Giza & Hovda, 2001)
Signs You May See (Acutely)
Recovery From Concussion:How Long Does it Take?
0
10
20
30
40
50
60
70
80
90
100
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+
All Athletes No Previous Concussions 1 or More Previous Concussions
N=134 High School athletes
WEEK 1
WEEK 2
WEEK 3
WEEK 4
WEEK 5
Collins et al., 2006, Neurosurgery
Focus on School Return & Support
"You can't educate a child who isn't healthy, and you can't keep a child
healthy who isn't educated." Joycelyn Elders
Effect of Concussion on School Learning &
Performance
Effect of School Learning & Performance on Concussion Recovery
SchoolKid’s Major “Job”
NewNew Learning/ Learning/ AcquiringAcquiring Knowledge Knowledge AcademicAcademic SocialSocial
PracticingPracticing incompletely learned knowledge incompletely learned knowledge
Mental/ Cognitive Mental/ Cognitive exertionexertion is essential to is essential to new learning/ practicenew learning/ practice
School professionals should watch for students who show increased
problems Paying attention Problems remembering or learning new information Inappropriate or impulsive behavior during class Greater irritability, less ability to cope with stress Difficulty organizing tasks Fatigue in class Onset of or worsening headaches
Concussion’s Effects on School Learning & Performance 80 students with concussions80 students with concussions
““Which specific types of problems are you Which specific types of problems are you experiencing in school?”experiencing in school?”
Students reported an average of 4 problems below. Students reported an average of 4 problems below. Headaches interfering Headaches interfering 71.3% 71.3% Can’t pay attn in class Can’t pay attn in class 62.5% 62.5% HW taking much longer HW taking much longer 59.5% 59.5% Difficulty studying for test/quiz Difficulty studying for test/quiz 51.9% 51.9% Too tired Too tired 50.6% 50.6% Diffic understanding material Diffic understanding material 44.0% 44.0% Difficulty taking notes Difficulty taking notes 28.8% 28.8%
Concussion’s Effects on School Learning & Performance
““Which classes are you having the most trouble with?”Which classes are you having the most trouble with?”(Percent reporting trouble in class) (Percent reporting trouble in class)
Parent Parent StudentStudent Math Math 60.3% 60.3% 73.7% 73.7% Reading/LA Reading/LA 38.1% 38.1% 46.1% 46.1% Science Science 38.1% 38.1% 47.4% 47.4% Soc Stud Soc Stud 38.1% 38.1% 40.8% 40.8% Foreign Lang Foreign Lang 38.1% 38.1% 38.2% 38.2% Music Music 6.3% 6.3% 17.9% 17.9% PE PE 7.9% 7.9% 10.5% 10.5% Art Art 3.2% 3.2% 5.3% 5.3% -None-None 25.4%25.4% 6.6% 6.6%
Effect of School Learning & Performance on
Concussion Recovery
86.6%83.3%
46.8%
3.0% 3.0% 3.2%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
Percent Reporting
Yes No Opportunity
Presence of Symptom Worsening
Cognitive Exertion - 3 Visits
Visit 1 (13 days) Visit 2 (28 days) Visit 3 (45.5 days)
N= 72 Gioia et al., 2010
Cognitive Demands of School Worsen Symptoms
British Journal of Sports Medicine 2009 43 (Suppl I) i76-i84.
Sources of Mental/ Cognitive Activity?
Prolonged concentrationProlonged concentration Prolonged homeworkProlonged homework Prolonged classes (block scheduling)Prolonged classes (block scheduling) Prolonged daysProlonged days Excessive TV, computer, socializing…Excessive TV, computer, socializing…
These sources and degrees of activity are likely to vary from person to person
Keys to Recovery Resting the brain & getting good sleepResting the brain & getting good sleep No additional forces to head/ brainNo additional forces to head/ brain Managing/ facilitating physiological recoveryManaging/ facilitating physiological recovery
Avoid activities that produce symptomsAvoid activities that produce symptoms Not over-exerting body or brainNot over-exerting body or brain
Ways to over-exertWays to over-exert PhysicalPhysical EmotionalEmotional Cognitive! Cognitive! (concentration, learning, memory)(concentration, learning, memory)
Athletic Therapy March, 2010
“Physical rest alone fails to address another key aspect of brain function in youth – mental exertion associated with school activities.”
What is cognitive “rest?”What is cognitive “rest?”
The concept of cognitive exertional activity (and rest) viewed The concept of cognitive exertional activity (and rest) viewed along a along a continuumcontinuum of activity of activity
No activity/full rest No activity/full rest Full activity/no restFull activity/no rest
In reality, In reality, nono cognitive activity/full cognitive rest not cognitive activity/full cognitive rest not practical/likely (unless asleep or comatose)practical/likely (unless asleep or comatose)
Therapeutic goalTherapeutic goal is to is to limitlimit cognitive activity to a level that is cognitive activity to a level that is tolerable, and does not exacerbate or cause the re-tolerable, and does not exacerbate or cause the re-emergence of symptomsemergence of symptoms
Cognitive ManagementCognitive Management
Supporting student recovery requires collaborative approach among school professionals, health care professionals, athletics, parents, and students.
All school staff should be educated/ informed about the returning student’s injury and symptoms
School staff must assist with transition process and making accommodations for student.
Purpose of Care Plan
Guide recovery
Educate
Manage exertional activity, safety
Return to School
Return to Sports
Summary• Concussions can have a significant effect on the Concussions can have a significant effect on the
injured student’s school learning injured student’s school learning • School learning can potentially have a significant School learning can potentially have a significant
effect on recovery from concussioneffect on recovery from concussion• Schools and school personnel play an important Schools and school personnel play an important
role in assisting the student with concussion.role in assisting the student with concussion.• Understanding and monitoring the student’s Understanding and monitoring the student’s
symptoms is critically important symptoms is critically important
• Assisting the symptomatic student by reducing Assisting the symptomatic student by reducing demands – physical and cognitive demands – physical and cognitive
• Gradual increase in academic demands as Gradual increase in academic demands as symptoms reducesymptoms reduce
• Return to sports participation, PE, or any other risk Return to sports participation, PE, or any other risk activity requires clearance from a health care activity requires clearance from a health care professional with training in concussion evaluation professional with training in concussion evaluation and managementand management
SummarySummary
Q & A
Questions for Schools to Ask and Prepare for
1.1. When a student is identified with a concussion, what is your When a student is identified with a concussion, what is your response? High school, middle school, elementary schoolresponse? High school, middle school, elementary school
2.2. What/ who is the team?What/ who is the team?1.1. Who does the parent contact?Who does the parent contact?2.2. Who will connect with the teaching team? Who will connect with the teaching team?
1.1. Method to disseminate student needs with Method to disseminate student needs with accommodations/ strategiesaccommodations/ strategies
3.3. Who will do what?Who will do what?4.4. What will you do?What will you do?5.5. How will you monitor the moving target of recovery, and adapt How will you monitor the moving target of recovery, and adapt
the accommodations as needed (i.e., this is not a black & the accommodations as needed (i.e., this is not a black & white situation)white situation)
6.6. What is program for in-servicing teachers about concussion What is program for in-servicing teachers about concussion and its effects?and its effects?
Support / Accommodations Procedures
Managing expectations for school demands in a Managing expectations for school demands in a student that is there in school “looking OK”student that is there in school “looking OK”
When does a student stay home, when does a When does a student stay home, when does a student return to school (criteria for partial vs full day)student return to school (criteria for partial vs full day)
How are you monitoring recovery across the day and How are you monitoring recovery across the day and across the week (hint – use a sx monitoring tool)across the week (hint – use a sx monitoring tool)
Where/ how will you provide key accommodations?Where/ how will you provide key accommodations? Rest breaksRest breaks Managing tests, AssignmentsManaging tests, Assignments GradingGrading
What can I do to prepare for a concussion?
Prepare a concussion action plan. To ensure that concussions are identified early and
managed correctly, have an action plan in place before the start of the school year.
This plan can be included in your school or district’s concussion policy.
Be sure that other appropriate school and athletic staff know about the plan and have been trained to use it.
What can I do to prepare for a concussion?
Educate parents, teachers, coaches, and students about concussion.
Parents, teachers, and coaches know their students well and may be the first to notice when a student is not acting normally.
Encourage teachers, coaches, and students to: Learn about the potential long-term effects of concussion
and the dangers of returning to activity too soon. Look out for the signs and symptoms of concussion and
send students to see you if they observe any or even suspect that a concussion has occurred.
Keep students with a known or suspected concussion out of physical activity, sports, or playground activity on the day of the injury
AND until a health care professional with experience in evaluating for concussion says they are symptom-free and it is OK for the student to return to play.
What can I do to prepare for a concussion?
Monitor the health of your student athletes. Make sure to ask whether an athlete has ever had
a concussion and insist that your athletes are medically evaluated and are in good condition to participate in sports.
Keep track of athletes who sustain concussions during the school year. This will help in monitoring injured athletes who participate in multiple sports throughout the school year.
What can I do to prepare for a concussion?
Small Group Work
Small Group Work
Small Group Work
Concussion/ mTBICDC Educational Materials
Heads Up: Concussion in High School Sports
Heads Up: Concussion in Youth Sports
Heads Up: Concussion in Your Practice
Heads Up to Schools: Know Your Concussion ABCs
www.cdc.gov/concussion
Educational Materials
Coaches, Parents, Student-athletes Coaches, Parents, Student-athletes Video Education: Video Education:
www.nanonline.org
www.concussion.orcas.com
www.usafootball.com
www.nfhslearn.org Fact SheetsFact Sheets Clipboard stickersClipboard stickers
Public Awareness &
Education
Video EducationCoaches, Parents, Athletes
.
USA Football
ACTive: Free Concussion Training for Sports
Coaches
Play Smart: Understanding
Sports Concussion
NAN-NATA w NFL/NHLRaising Concussion Awareness
Educational DVD, "Concussions in Football (Hockey): Signs,
Symptoms and Playing Safe"
Concussion Clipboard
Electronic Clipboard
Coach/ Parent Electronic ClipboardCoach/ Parent Electronic Clipboard
Using Technology to AssistConcussion Symptom
Management
9:30am
Alert: Your symptoms are worsening. Time for
a rest break.