Jonathan French, PsyDNeuropsychology Fellowfrenchje@upmc.eduUniversity of Pittsburgh Medical CenterDepartment of Orthopaedic SurgeryUPMC Sports Concussion Program

Effects of Concussions on Academic Functioning and Case Presentation

15 year old, SophomoreHonors student, High Average standardized testing No other medical history-no prior concussion

Strong migraine history in maternal family

In retrospect, difficulties with concussion started on September 11, 2009

Case Example: High School Quarterback

Initial injury in video caused bilateral blurred vision, dizziness, photo/phonphobia, nausea, difficulty with play calls

No LOC, amnesia or mental status changeNever reported hit or symptoms to ATC, though told teammates Second event in video worsened symptoms

That evening, told parents of symptoms (minimized difficulties)No other medical intervention

Played remainder of seasonSymptoms ebbed/flowed depending upon exertion and contact to headGrades dropped during course of season (Straight A’s to C range)Symptoms persistent throughout entire seasonSustained “another” concussion 10/30/09 (2nd to last game)-posterior blow

• Reported to ATC week after game/Referred to UPMC

Case Example: High School Quarterback

Show Video

November 16, 2009 Evaluation (2 Months after initial event)Headaches daily in school (7/10-generalized pressure), moderate fatigue, “feeling slow”, fogginess, general dizziness, distractible, short term memory difficultyDiscussed inherent pressure of playing quarterback, team culture of playing through injury, pressure from coaches/family/friends

“Knew it was concussion, but nothing serious”“Would be fine in long run”“Good time to report injury given break from conditioning-no football responsibilities”

Father nonchalant, mother very concerned-discussed team/community culture of football

Physical evaluation indicated convergence insufficiency, provocative dizziness with horizontal/vertical saccades and gaze stability, balance WNLImPACT Testing

Case Example: High School Quarterback

Show ImPACT Data

Recommended formal Vestibular Evaluation (UPMC-Eye and Ear Institute/Center for Rehabilitation Services)Patient strongly desired to remain in school

Allowed ½ days for 2 weeksProvided full academic accommodations-including no tests for 3 weeks, ½ work assignments, books on tape if possible, extensions on all assignments, leaving class early, avoiding high stimulus areas, excused absences from school-recommended meeting with all teachers

Return evaluation in 2 weeks to monitor status

Case Example: High School Quarterback

Background of Academic Accommodations

• In the early 2000’s, due to the increase of concussion, schools approached UPMC to help develop a plan for students with concussion

• UPMC’s sports concussion program wanted to collaborate with local schools to create an educational plan for individuals who are have a head injury

• This lead to a creation of an Academic Accommodations form, which has been ever changing since it’s inception, and we continue to want to work with schools to improve it

Impact of School and Learning on mTBI

• Most educators, parents, and medical providers are aware of the deleterious impact of physical exertion on concussion symptoms and recovery, and are compliant with recommendations to reduce physical activity.

• Cognitive Exertion (Thinking) and the added stimulation of the school environment can significantly increase symptoms, even when the student has begun to recover

• Research has demonstrated generalized hyperactivation with concussion that is likely related to symptom increases when returning to school.

• Obvious Means: Testing, Group Work, Movies, Shop Class, Overhead lighting

• Subtle or Hidden Causes: Background noise (cafeteria, movement during and between classes), Taking notes (especially off of a projector), Sustained attention

Understanding the Symptoms Help to determine appropriate accommodations HUGE individual differences Can be Cognitive, Somatic, or Emotional Can wax and wane throughout the day

1st period “ok” by 8th they are struggling Student may not look or even act injured

Students are able to laugh when they are concussed

Some are able to continue to do well Don’t assume someone is “faking”; but we are

aware this occurs

Symptoms in the Classroom– Cognitive Difficulties

• Attention/Concentration Problems

• Difficulty with memory• Slowed processing• Difficulty with Multi-

tasking– Physical Symptoms

• Difficulty to do well, if in significant pain

• Convergence Insufficiency• Vestibular Dysfunction

– Sleep Disruptions• Not sleeping at night it is

difficult to perform well in school

• Fatigue throughout the day

– Emotional Instability• Anxiety about catching up

When Accommodations Fail…• Communication problems: Staff are not aware of the

injury or the severity of the problems (parents, guidance counselor, school nurse are key)

• Education problems: Staff shrug off injury because the student “looks fine,” “just had his/her bell rung,” or “this is only their first concussion, I had 10 when I played football and it didn’t bother me” (individual differences)

• Resistance: Because of the extra time and effort involved in accommodations, staff are resistant to providing notes, checking off assignments, etc.

Goals of Academic Accommodations

• Goals: A collaborative effort– Create a way for educators to know that the student is injured and based on the

evaluation, understand that certain tasks would provoke symptoms and prolong recovery

– To help students learn the core information needed to move on, without effecting their recovery

– Do not want students grades to suffer because of the injury– Balance between recovery, academics, and normal activities– Provide the right environment for recovery, as quick as possible

• It is NOT: – UPMC telling you how to educate these students

• You are the educational professionals• We want to collaborate with schools

– A “pass”– Dismiss them from work/learning

• The recommendations were made based on the assessment at the time of the visit

• Recommendations part of treatment for this medical condition

• Formalize a 504 plan if necassary

Attendance Recommendations

• No school• Initiate Homebound education• Half days

– Modified days – core classes, extra study periods• Full Days

Testing

• Students will not be as effective in testing situations, and they most likely will exacerbate symptoms

• Modifying test schedules, length, format, etc. is beneficial

Reducing and Modifying Workload

• Reduce the amount of total work• Modify the work by shortening assignments• Changing modalities• Auditory learning• Audit Classes

Notes, Breaks and Extra Time• Note taking can be extremely provocative of

symptoms• Have the student listening to lectures having pre-

printed notes, scribes, etc.

• Allow the students to take breaks throughout the day

• Allow students extra time to complete assignments

Other Accommodations

• Allow students the opportunity for food and water if needed to help with symptoms

• Due to light sensitivity, allow sunglasses• Modify computer screens• Modify busy/disturbing environments• No gym class

SUMMARY– Communication at all levels is key

• Both educators and treatment providers should work together

– Give the student the right environment to recover– Recovery is quicker and safer when students receive a

consistent message from all involved in their care– Discussing options with injured student can be

empowering– Ideally, injured students’ grades should not suffer due to

this temporary disability– “Healthy” appearance of student is usually a difficulty– Utilize available references, and encourage

students/parents/administration to do the same

November 30 Evaluation Vestibular evaluation indicated convergence insufficiency, difficulties with dynamic visual acuity, VOR exercises provocative for dizziness, posturography WNL

Home-Based PT outlined, Patient compliant

Symptoms not improved and persistentPatient vocalized concerns over injury, response from coaching staff, etc.

“Play through pain culture”Both parents understanding and concernedTeachers helpful at providing accommodationsFather trying to “educate” others regarding injury

Vestibular screening improved, but remained abnormalImPACT Testing

Case Example: High School Quarterback

Show ImPACT Data

Continued Vestibular Therapy-no exertion until WNLRecommended homebound instructionRecommended medication referral

Dr. Camiolo-Medical Advisor-UPMC Sports Concussion ProgramAmantadine 200mg

Follow up in 2-3 weeks

Case Example: High School Quarterback

NEUROPSYCHIATRIC • More emotional• Sadness• Nervousness• Irritability

COGNITIVE SYMPTOMS• Attention Problems• Memory dysfunction• “Fogginess”• Fatigue• Cognitive slowing

SLEEP DISTURBANCE • Difficulty falling asleep• Sleeping less than usual

MIGRAINE (PHYSICAL SX)• Headaches • Visual Problems• Dizziness• Noise/Light Sensitivity• Nausea

Factor Analysis, Post-Concussion Symptom Scale (Pardini, Lovell, Collins et al. 2004)

N=327, High School and University Athletes Within 7 Days of Concussion

NOTE:*Off-label use

Emotionality

SSRIsEscitalopram (Lexapro)

Sertraline (Zoloft)

Therapy

Sleep Disturbance

Melatonin

Trazodone

Cognitive Symptoms

NeurostimulantsAmantadine*

Methylphenidate*

Atomoxetine (Strattera)*

Somatic Symptoms

Headaches Prophylaxis Propranolol*

Verapamil*

Amitriptyline*

Escitalopram (Lexapro)

Sertraline (Zoloft)

Vestibular Therapy

UPMC Concussion ProgramTreatment/Rehabilitation Protocol

December 18, 2009 (3 months post-injury) Headaches 1/7 days (1/10, 20 minute duration), mild perceived difficulty with short-term memoryNo other symptoms reportedDischarged from Vestibular therapy-all WNLStarted Exertional Physical Therapy

Sean Learish,PT-Center for Rehab Services-Director of Exertional PT- UPMC Sports Concussion Program

ImPACT Testing

Case Example: High School Quarterback

Show ImPACT Data

December 18 recommendationsReturn to full school, minimal accommodations (breaks from class if needed, tutoring in difficult classes, extensions all assignments)Progress with exertional therapy to Stage 3-4No contact sportsContinue AmantadineFollow up 1 month

Case Example: High School Quarterback

January 11, 2010 (4 months post-injury) Off AmantadineReported circumscribed short term memory difficultiesDoing well in school-full curriculumNo other symptoms reportedStage 4 Physical Exertion-no difficultiesVestibular screening WNLImPACT Testing

Case Example: High School Quarterback

Show ImPACT Data

January 11, 2010 Recommendations Continue Exertion as toleratedFollow up in February for monitoring of status

Case Example: High School Quarterback

February 22, 2010 Evaluation100% asymptomatic-no difficulties reportedFull physical and cognitive exertionGrades returned completely to normal

Case Example: High School Quarterback

Show ImPACT Data

February 22, 2010 RecommendationsFull clearance back to all sports, including footballQuotes from Family:

Both “Felt educated about injury”Strong desire to “educate others”Reported misperceptions of others

Concussion is always repetitive and cumulativeSon has “permanent damage”Son would “never” return to footballSon would “never be the same cognitively or physically”Son should “never play football again” (from same people who questioned veracity of injury to begin with)“Poor education throughout community-from coaches to clinicians”

Without academic accommodations probably would have taken even longer to recover

Case Example: High School Quarterback

Questions?

Jonathan French, PsyDNeuropsychology Fellow

UPMC Sports Concussion Programfrenchje@upmc.edu