What About Return-to-Learn?

4 Nov

Two important groups released information about concussions and youth recently.  The Institute of Medicine recently released its Sports-Related Concussions in Youth: Improving the Science, Changing the Culture, addressing concussions for the youth (obviously by the title).  This was on the heels of the American Academy of Pediatrics release of their second report on concussions, addressing the return-to-learn aspect.  I offered some opinions on both of the reports via Twitter, but was really underwhelmed by the information in both documents.  It seems to me that even though the car is pointed in the right direction the gas pedal is being confused with the brake pedal.  At best I feel the community is driving though the rear-view mirror.

A loyal follower and some time contributor, Dorothy Bedford, a self-described “parent activist in concussion education, awareness and advocacy, and newly retired school board member in Princeton NJ,” has penned the following post regarding return-to-learn and the AAP paper.  This is not your typical parent; “I come by the interest in return-to-learn honestly, both from my daughters’ concussion and from the point of view of a school board member – with the opportunity to help protect the brains of all students.”

With all of that said, below is her post.  Thank you, Dorothy.  As a reminder, the inbox is always open to contributors.

==========

The Pediatricians Weigh In on Returning-to-Learning – A Mixed Review

The American Academy of Pediatrics has released its second major clinical report on concussions. It’s a good first step which will help many pediatricians begin to address the second most important issue in concussion management (after “remove from play,” and before “return to play”).  On the other hand, ten pages limits the territory it can cover; there’s little new for the ATC who takes a broad view of concussion recovery; the report wildly underplays the complementary role of the neuropsych, and omits any discussion of some important symptoms. I think the most important contribution this report makes will be nudging school administrators to action, especially those who have been inattentive or resistant to dealing with concussions in the classroom and gradual return to learn. It’s hard to ignore the AAP.  I will confess, since its release my reaction has swung up and down with each re-reading. Five days later, I hope this will be a balanced review. I like to keep the conversation open.

“Returning to Learning Following a Concussion” was published on October 27 (full report here: http://pediatrics.aappublications.org/content/early/2013/10/23/peds.2013-2867.full.pdf+html)  complementing AAP’s 2010 clinical report on “Sport-Related Concussions in Children and Adolescents”. The lead author on both reports is Dr. Mark Halstead, a specialist in non-operative sports medicine at Washington University in St. Louis. Neuropsychologist Dr. Gerald Gioia of National Children’s Medical Center was a consultant. Dr Gioia is a co-author of the CDC’s Physician’s ACE Return to School form, which should be in the hands of every student athlete and their parents for any concussion-related visit to a doctor (http://www.cdc.gov/concussion/headsup/pdf/ACE_care_plan_school_version_a.pdf ). Six other professional societies have endorsed this report.

The Good:

For pediatricians in areas with thin or no sports medicine/neuropsych coverage, this report is going to be very important, and it stresses continuing education of all parties with responsibility for a student’s recovery.  It also has a decent list of resources and references.  The report recommends that pediatricians consider utilizing a collaborative team approach to help a student recovering from concussion: a medical team and two school teams, one for physical activity and one for academics.  It introduces a new and useful term to the RTL conversation: “academic adjustments” for short-term needs, in addition to accommodations and modifications.  The Tables and Figures are concise and generally present information well, but omit any psychological or psychiatric signs or symptoms (more below). The report even goes so far as to emphasize that a “cookie cutter approach to managing a concussion and a return to the classroom cannot be applied,” due to the highly individual nature of each injury.   Good on ya’, mate.

The Less Good:

Cognitive Rest. Give the authors credit for including this statement in the background section. “There is increasing evidence that using a concussed brain to learn may worsen concussion symptoms and perhaps even prolong recovery.”  Wow !  Are they recommending rest?  But, the report backs off, asserting that “there is insufficient research on the role of cognitive rest, although recent research suggests benefit to the concept of cognitive rest both early and late in the recovery.”  And similarly, “Determining the appropriate balance between how much cognitive exertion and rest is needed is the hallmark of the management plan during cognitive recovery.”  Say what? Are we resting the kid’s brain, or not? To me, this is neuropsych territory, not a medical judgment, although the report got an endorsement from the National Association of School Psychologists  Overall, I think the role of rest, both physical and cognitive, and the evolving nature of appropriate cognitive rest throughout recovery is under-described for a report asserting authority on returning to learning, by definition a cognitive activity.

Too Much Discussion of Extended Cases. The report devotes valuable real-estate covering a very specific situation, the lengthy case requiring that an Individual Education Plan (I.E.P., under the federal IDEA legislation) needs to be set up. Come on: 90 days of elapsed time is very fast to set up an IEP. It’s a big commitment. Mention the possibility and move along, because this report isn’t about those patients.  (Note: my own daughter’s PCS was 14 months. This report would not have helped us.) Take the child to a major concussion clinic .

The Critical Omissions.

A better use of the word count would have discussed other possible specialists on the medical team. In the case of a moderately severe concussion (lasting more than ten days), a trip to an optometrist to check for visual convergence issues (the source of blurry vision), or to  a qualified physical therapist for vestibular rehab therapy addressing balance/dizziness issues either of which might help overcome school attendance challenges in classrooms and hallways. Finally, the major omission of psychological or psychiatric signs or symptoms in Table 1 (impaired judgement, irritability, labile emotions, depression, or suicidal ideation) is a major disservice to clinical practitioners, families, school personnel, and the children. This report leaves a lot of decisions up to the family, but the psychological symptoms are the hardest for families and administrators to understand, and generally difficult for the student recognize, too. Which is why, contrary to the inclination of the AAP report, many concussion recovery decisions should NOT be left to the family, much less the student.  Although concussion-related self-harm is relatively rare, it does exist and deserves mention. It can be brought on by school problems as much as by chronic pain such as concussion migraine.  This country is in a youth sports concussion crisis, and responsible adults need to take charge and make decisions NOW appropriate to saving our kids’ brains for the future well-being of our society.

Finally, I can’t help but bring readers attention to what remains the best, most comprehensive guidance on return to learn: Dr. Rosemarie Moser’s 2012 book, “Ahead of the Game: the Parents’ Guide to Youth Sports Concussion,” reviewed elsewhere here at TheConcussionBlog.

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9 Responses to “What About Return-to-Learn?”

  1. Educator Mom November 4, 2013 at 20:00 #

    I agree with much of Ms. Bedford says in response to this report. However, I do think it is important to present the educational options that are available to students who are dealing with extended recoveries. It’s important for physicians, educators, and families to see that information. My son was 24 months into his PCS when we finally got enough support and pressure to convince the school to offer him an Individualized Education Plan. By that time he had been discriminated against due to his disability and his progress and right to get a free and appropriate education was largely ignored. His GPA dropped by more than a full point and his class rank plummetted. And worst of all, he learned not to say anything about his symptoms and learning issues because students and teachers would just question him and harass him about a disability they could not see and did not understand. There is not enough time left in his high school career to correct the wrongs that were committed and that will now alter his future. It would be wonderful to be able to say that he is the only one who has walked this path but he is not the first and certainly will not be the last.

    When the disability of TBI (concussion/traumatic brain injury) are ignored in the schools, these students are asked to do in the classroom what their brains cannot do. This contributes to symptoms and the increase in stress level. The lack of success they feel in the classroom (on top of the fact that they have probably had to delay participation in their sport or abandon it all together) further increases the risk of depression and psychological distress. Frankly, the topic of “return to learn” should be addressed BEFORE the topic of “return to play”. Students should be students first and athletes second. If the symptoms of a concussion prevents them from being successful in the classroom, they should not be returning to the field of play. But first we MUST get schools to understand the cognitive issues these students face and deal with them head on rather than sweep them under the carpet as so many schools are doing. The sooner we can do that, the sooner we may see student recovering from their symptoms and returning to their lives, school, AND sports.

  2. brokenbrilliant November 5, 2013 at 09:19 #

    This might broaden the discussion about the importance of rest after concussion: http://www.youtube.com/watch?v=96aZtk4hVJM

    Conclusive, substantiated proof that sleep helps clear neurometabolic waste — and if I understand it correctly, metabolic waste is one of the issues we face after concussion — a cascade of all sorts of interesting biochemicals and waste products that aren’t there normally.

    For an injured brain to heal, wouldn’t it make sense to take out the trash, so to say, and allow for the time to do so?

    Also, if metabolic waste is produced by cognitive activities, and one’s system is already overloaded with neurometabolic waste, wouldn’t it make sense to have an extended cognitive rest period post-concussion, to ensure that additional “sludge” isn’t being added to an already overtaxed system?

    Now that we have additional research, making a case for extended cognitive time-out and rest, might be a little easier to do.

    Here’s hoping.

  3. brokenbrilliant November 5, 2013 at 09:20 #

    Reblogged this on Broken Brain – Brilliant Mind and commented:
    Important considerations for student athletes, post concussion. Note the blogger’s emphasis on “student” before “athlete”.

    • From pages 111 & 112 of Dissertation entitled:

      A Preliminary Investigation of Active and Retired NFL Players’ Knowledge of Concussions — D. Brady (2004)

      Strong consideration should be given to creating different and more developmentally appropriate return-to-play concussion grading systems for adolescents and children. Differing concussion management systems should be considered due to a young person’s developing brain and overall neurological system, coupled with the risk of the second impact syndrome (Brady, 2002; 1999; Patel & Greydanus, 2002).

      Patel and Greydanus (2002) cautioned that in typically- developing adolescents’ CNS, “there is continued maturation of the neurologic system and improvement in higher cognitive functioning” (p. 571), and thus injury could adversely impact the appropriate developmental growth of the brain.

      In the same vein, athletes who present with a preexisting brain dysfunction–such as an attention deficit disorder, learning disability, or seizure disorder–may place their brain at further risk for additional brain damage when they participate in football or other contact sports (Brady, 1989; Brady, 1999; Brady, 2002; Collins et al., 1999). A growing body of research indicated that not only does a brain become compromised by concussion, it is also more susceptible to additional concussions. Therefore it seems plausible that any compromised brain may be more susceptible to further dysfunction by subsequently sustaining a concussion. Research that addresses this concern is strongly encouraged.

      Extensive sports-related concussion research needs to be conducted pertaining to individuals aged 15 to 24. Although this age group has the highest frequency of concussions, there is a paucity of sports-related concussion research regarding this population.

      One of the areas this research needs to better address is the student-athlete’s ability to safely return to play and adequately function within the classroom setting after he or she sustains a concussion. Unfortunately, at the present time, functional recovery from a concussion typically focuses on when an athlete may return to participating in sports, ignoring how well the student part of the student-athlete is able to function within the classroom setting.

      When children and adolescents present with attention, memory, or other information- processing deficits, TBI should be considered as a possible diagnosis, as these symptoms are hallmark manifestations of TBI (Alexander, 1995; Lovell, 1998; Reitan & Wolfson, 2000). Through clinical experience, this author has seen children who had been diagnosed with an attention deficit disorder; upon receiving a more comprehensive assessment, they were found to be displaying symptoms of an acquired traumatic brain injury.

      ==========================

      Excerpts from 2011 NASP article entitled:
      Sport-Related Concussions – Don Brady, PhD, PsyD, NCSP & Flo Brady, BSW

      The uniqueness of each concussion results in multiple and complex symptoms; thus, there are many faces of concussions, as no two concussions are similar.

      Potential SRC concussion symptoms comprise a longer list of symptoms than are often noted on various common SRC symptoms checklists.

      During the 1990s, some SRC experts concurred that athletes should not return to sports activities until they are asymptomatic for a designated period of time, both at physical rest and during physical exertion. More recently, the concept of cognitive rest was introduced as part of SRC management. Because the brain influences physical, cognitive, and emotional aspects of an individual, it seems logical and essential that the concept of emotional rest is also incorporated into this management framework. The concept of rest, along with its three components, needs to be more clearly operationally defined for application to concussion management.

      • Although concussions are common within the pediatric age group, there is a paucity of SRC research regarding this population (Brady, 2004, Purcell, 2009). The recognition, assessment, and management of concussions are not simple tasks.

      • There exist many faces of concussions that require individualized healthcare provided by an interdisciplinary team of knowledgeable clinicians. Moreover, a concussion is a family affair. The brain injury adversely impacts the whole family system. Thus, it is important that all family members’ needs are addressed in the journey to functional recovery. …

      • Because the neurological system and cognitive functioning continues to mature through adolescence, a subtle pediatric brain injury could adversely impact this development. It is also possible that a neurocognitive disability would not be detected until a later period of time.

      • Although athletes may appear to have fully recovered from concussion, their brain may require more effort or energy to complete a task than was required prior to sustaining a concussion (Gronwall, 1989). Because the brain has been injured, the use of the concept of “functionally recovered” is encouraged over “recovered.” Individuals recovering from concussions may typically display fatigue along with difficulty with concentration, memory, new learning, organization, insight, irritability, and emotional self-control (Wrightson & Gronwall, 1999). The developing brain of a child or adolescent appears to take a longer period of time to functionally recover from sustaining a concussion than does the brain of an adult.

      • Unfortunately, at the present time, functional recovery from a concussion typically focuses on when an athlete is resuming participation in sports, ignoring how well the student part of the student-athlete is able to adequately function within the classroom, home, or social setting.

      • Individuals who sustain a concussion should not drink alcoholic beverages or utilize street drugs during the functional recovery process. Use of alcohol and other drugs while functionally recovering from a concussion may not only impede the healing process but may also further damage the brain.

      Suggestions for Returning to Play, School, Home, and Socializing

      The complex, varying, and individual central nervous system response to a brain insult and resultant concussion injury not only justifies but also requires a comprehensive assessment from a readily available and qualified multidisciplinary team of healthcare providers (Brady, 2004; McKeag, 2003).

      The utilization of a multidisciplinary team is particularly essential since consequences of a concussion include both neurological and nonneurological effects. Suggested members of this healthcare team may include the following: physician, neurologist, neurosurgeon, psychologist, neuropsychologist, school psychologist, teachers, school administrators, optometrist, ophthalmologist, coaches, athletic trainer, speech pathologist, occupational therapist, and physical therapist.

      Equally important is the carefully gathered input from close family members and significant others to assist in the concussion assessment and return-to-various-activities decision- making process. In order to fully protect the student-athlete’s health and corresponding safety, return to play, school, home, and socializing risks also need to be comprehensively assessed and thoroughly explained by the team.

      Individual accommodations. Physical, cognitive, and emotional caution should be exercised for the injured student. The student component of the student-athlete should be prioritized over the athlete component: The student’s performance within the classroom setting should return to normal before engaging in any athletic related activities.

      Pressures to prematurely return to and succeed on the athletic field, in school, in part-time employment, and in socializing must be minimized.

      The amount of energy possessed by the concussed individual for each area of function has been reduced since the injury occurred (Wrightson & Gronwall, 1999).

      To allow for adequate breaks, a quiet area should be provided in each setting that the student is present. Nurse’s offices are often a hub of activity and overstimulating for the person who requires a low-traffic and tranquil setting.

      The new 3Rs apply to the essential ingredients of a tranquil setting: Relaxing, Reenergizing, and Refocusing (Returning to adequate focusing). It may even be advisable for the athlete to initially convalesce exclusively within a tranquil and low-stimulation setting at home to effectively obtain physical, cognitive (neurocognitive), and emotional rest.

      Adjustments to school program. Suggested school adjustments include an initial meeting and periodic ongoing parent meetings with all teachers and administrators regarding the implications of the concussion on the student and ongoing communication between the school staff and family pertaining to the student’s level of functioning.

      Reduced course work (and possible withdrawing or taking incompletes from some courses) may be necessary to diminish cognitive demands and potential accompanying emotional stress. Adjusting the number of school days and hours attended each week, participating in less cognitively demanding classes, and putting into place individualized special education accommodations or 504 plans may also be necessary.

      Overlapping individualized concussion management plans should be written for return to play, school, home, and socializing to provide a consistent approach for the injured and suffering athlete. Furthermore, extensive concussion education is an essential cornerstone of effective concussion management within the school and home settings, and for the suffering student.

      Counseling formats may also need to be adapted to the presenting symptoms. For example, a shorter than usual session or the use of a low stimulation and/or noise-free counseling room may be necessary due to the reduced ability of the student to sustain attention and concentration.

      Social activities. Numerous social activities may also have to be modified or eliminated. Participation in afterschool activities such as dances, house parties, memberships in various organizations, part-time employment, driving an auto or riding a bike, at-home responsibilities, and use of various modern technology such as cell phone talking and texting, computer and videogame use, music volume, and iPod use need to be closely scrutinized and discussed with the injured student.

      Physical, cognitive, and emotional demands could be excessive within all these various activities. Typical demands of adolescence also need to be revisited and discussed in a gentle manner. The serious implications of alcohol use and other street/recreational drugs after sustaining a concussion need to be shared by parents with their concussed child.

  4. Kids SRC Doc November 5, 2013 at 21:32 #

    Nice review. However, while cognitive and physical rest are hallmarks of treatment, the report is correct in stating how much cognitive rest is helpful (intensity and duration). For example, there are providers that will keep kids home from school until they have 100% recovered – which is absolutely silly (IMO). The medical community needs to point out where further research can help us improve/refine treatment.

    Agree on the psychological omissions. They should be in there.

    Disagree on the optometrist – a good concussion provider should be able to detect gaze stability and oculovestibular disorders as well as convergence insufficiency. If they cannot, then that provider is not at the top of their game with concussion care.

    I personally think this document needs to be in the hands of school administrators > health care providers.

    • Re Visual assessments:

      Reminder… the vision / occipital area of the brain is located opposite the frontal lobe…and thus ripe for adverse coup – contre coup effects of concussion / brain injury.

      Visual assessments may be more complex than noted in this post.

      Several eye doctors that I have communicated with re concussions have offered some similar valuable info and insights. A response from one of the doctor’s follows:

      I understand that you are inquiring about information regarding visual treatment of concussion or traumatic brain injury.

      In the acute phase, we test for the possibility of retinal detachments as that would require immediate intervention. Once the acute phase is complete, and patient is cleared to return to visual activities, then a complete assessment is done.

      At that time depending on the severity of the injury, we will determine the status of:

      1. visual field defect or visual neglect

      2. acuity loss

      3. diplopia

      4. binocular dysfunction

      5. suppression

      6. visual perceptual or visual processing delays including but not limited to: visual memory, visual discrimination, figure ground, visual gross and fine motor, executive functions as tested with PACE (processing and cognitive enhancement).

      .

    • Educator Mom November 7, 2013 at 20:32 #

      I’m not so sure it is “silly” to keep kids out of school until they have 100% recovered. If cognitive stress exacerbates the symptoms and the healing process, it is worth the risk to get them back into the classroom just to say they are back in the classroom. There are students who report being back in the classroom; not remembering what they are taught; not even remembering that they even took a test. So what good has it done to get those students back in the classroom? Their symptoms are exacerbated AND they have not learned anything.

      IF a student returns to school before they are 100% recovered, they should NOT return without a very clear plan in place (504 or IEP…Individualized Education Plan) and without the teachers fully understanding how this unseen disability may affect the student’s learning process. Too many schools are taking a “wait and see” approach to the detriment of the these students.

      As for the optometrist issue…our own personal experience disproves your thoughts on the subject. My son was under the care of a quality concussion provider, highly rated in our state, and continues to be under that care nearly three years later. About six weeks post-concussion, I made an appointment with his eye doctor on a bit of a whim due to just a few comments he made regarding his vision. We were looking for anything that might help. His eye doctor discovered some damage that we knew was directly related to the concussion as he had just recently had a normal eye exam. I will never forget when my son put on the glasses that were prescribed to assist with the vision related aspects of his injury. He said, “it is like seeing in HD.” When he came out of the initial deep fog post-injury, he no longer even remembered what his vision had been like before the injury and was now amazed to see what the world looked like again with just a little added support. Visual assessments can be another important piece to the puzzle of concussion recovery and/or accommodations/modifications.

      • !- Thank you Educator Mom for reporting your real-life experience re vision issues.

        2- Let’s apply logic & common sense when discussing the concept of rest…

        Given the brain controls 3 core aspects of functioning:

        Physical

        Cognitive and

        Emotional

        Then logically rest should be applied to ALL 3 areas of brain functioning.

        When I hear voiced ” the lack of evidence ” mantra, it reminds me of the various ” Dr No’s ” that exist…

        and who attempt to discredit fundamental concerns that arise within the field of concussions / brain injuries via the use of this pseudo-science mantra…

        Furthermore, it is important to note that the ” absence of evidence is NOT the evidence of absence. “

Trackbacks/Pingbacks

  1. Return to learn following a concussion: Is this within our scope of practice as Athletic Trainers (ATs)? « Board of Certification, Inc. - December 13, 2013

    […] in patient management. Recently, The Concussion Blog reviewed the AAP’s position statement, found here. The review posted makes valid points, and the overwhelming undertones are that a comprehensive […]

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