Jonathan French, PsyD Neuropsychology Fellow frenchje@upmc

1. Effects of Concussions on Academic Functioning and Case Presentation Jonathan French, PsyD Neuropsychology Fellow frenchje@upmc.edu University of Pittsburgh Medical Center Department of Orthopaedic Surgery UPMC Sports Concussion Program

2. 15 year old, Sophomore Honors 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

3. Initial injury in video caused bilateral blurred vision, dizziness, photo/phonphobia, nausea, difficulty with play calls No LOC, amnesia or mental status change Never 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 season Symptoms ebbed/flowed depending upon exertion and contact to head Grades dropped during course of season (Straight A’s to C range) Symptoms persistent throughout entire season Sustained “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

4. Show Video

5. Case Example: High School Quarterback • 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 difficulty • Discussed 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 WNL • ImPACT Testing

6. Show ImPACT Data

7. 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 weeks Provided 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

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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

15. 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

16. Attendance Recommendations • No school • Initiate Homebound education • Half days • Modified days – core classes, extra study periods • Full Days

17. 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

18. Reducing and Modifying Workload • Reduce the amount of total work • Modify the work by shortening assignments • Changing modalities • Auditory learning • Audit Classes

19. 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

20. 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

22. 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

23. 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 persistent Patient vocalized concerns over injury, response from coaching staff, etc. “Play through pain culture” Both parents understanding and concerned Teachers helpful at providing accommodations Father trying to “educate” others regarding injury Vestibular screening improved, but remained abnormal ImPACT Testing Case Example: High School Quarterback

24. Show ImPACT Data

25. Continued Vestibular Therapy-no exertion until WNL Recommended homebound instruction Recommended medication referral Dr. Camiolo-Medical Advisor-UPMC Sports Concussion Program Amantadine 200mg Follow up in 2-3 weeks Case Example: High School Quarterback

26. Factor Analysis, Post-Concussion Symptom Scale (Pardini, Lovell, Collins et al. 2004) N=327, High School and University Athletes Within 7 Days of Concussion

27. UPMC Concussion Program Treatment/Rehabilitation Protocol • Emotionality • SSRIs • Escitalopram (Lexapro) • Sertraline (Zoloft) • Therapy • Somatic • Symptoms • Headaches Prophylaxis • Propranolol* • Verapamil* • Amitriptyline* • Escitalopram (Lexapro) • Sertraline (Zoloft) • Vestibular Therapy • Cognitive Symptoms • Neurostimulants • Amantadine* • Methylphenidate* • Atomoxetine (Strattera)* • Sleep • Disturbance • Melatonin • Trazodone NOTE: *Off-label use

28. Case Example: High School Quarterback December 18, 2009 (3 months post-injury) Headaches 1/7 days (1/10, 20 minute duration), mild perceived difficulty with short-term memory No other symptoms reported Discharged from Vestibular therapy-all WNL Started Exertional Physical Therapy Sean Learish,PT-Center for Rehab Services-Director of Exertional PT- UPMC Sports Concussion Program ImPACT Testing

29. Show ImPACT Data

30. December 18 recommendations Return to full school, minimal accommodations (breaks from class if needed, tutoring in difficult classes, extensions all assignments) Progress with exertional therapy to Stage 3-4 No contact sports Continue Amantadine Follow up 1 month Case Example: High School Quarterback

31. January 11, 2010 (4 months post-injury) Off Amantadine Reported circumscribed short term memory difficulties Doing well in school-full curriculum No other symptoms reported Stage 4 Physical Exertion-no difficulties Vestibular screening WNL ImPACT Testing Case Example: High School Quarterback

32. Show ImPACT Data

33. January 11, 2010 Recommendations Continue Exertion as tolerated Follow up in February for monitoring of status Case Example: High School Quarterback

34. February 22, 2010 Evaluation 100% asymptomatic-no difficulties reported Full physical and cognitive exertion Grades returned completely to normal Case Example: High School Quarterback

35. Show ImPACT Data

36. February 22, 2010 Recommendations Full clearance back to all sports, including football Quotes from Family: Both “Felt educated about injury” Strong desire to “educate others” Reported misperceptions of others Concussion is always repetitive and cumulative Son has “permanent damage” Son would “never” return to football Son 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

37. Questions? Jonathan French, PsyD Neuropsychology Fellow UPMC Sports Concussion Program frenchje@upmc.edu