A Student and a PE teacher walk into your office……

1. A Student and a PE teacher walk into your office……

2. Why is this important to you? No one worried in the good old days about non-athletes Child abuse Domestic violence “Extreme sports”

3. Time course of recovery Collins, et al. Neurosurgery 58:275-286, 2006

4. How can I tell if a student is hurt? • May not be the athlete- could have happened outside of school, in gym class, slip and fall, etc • Symptoms may be delayed or not manifest until brain is cognitively stressed • Student complains of symptoms

8. Consistent message to the Student (and parents) The injury is real • Waiting for a full recovery is critical. • Prolonged recovery or even catastrophic injury by returning to activity too soon • Academic accommodations can be provided during recovery

9. COGNITIVE • Fogginess • Concentration • Memory deficits • Cognitive fatigue SLEEP DYSREGULATION Falling asleep Fragmented sleep Too much/too little sleep SOMATIC Headaches Dizziness Light/noise sensitivity Tinnitus MOOD DISRUPTION Irritability Sadness Anxiety Adapted from Camiolo Reddy, Collins & Gioia, 2008

10. Wake up fatigued • Develop headaches sitting in class • Can’t fully grasp class material • Feel worse as the day wears on • Bothered by light/sound at school • Feel more exhausted after school • More symptomatic trying to do homework • Upset and worried they are falling behind • Go to bed feeling worse

11. Post-injury Symptoms • Improve with rest… • Physical/sports exertion • Mental exertion • Sustained attention in class and during school day • Reading • Homework • Tests/quizzes/standardized testing • Computer vsiPad use

12. Risk factors for prolonged recovery • Higher number of concussions/mTBI • mTBIsoccurring too close in time • Re-injury prior to full recovery • Pre-existing learning disability or migraine issues Physical exertion OR cognitive stress can cause symptom flare-ups & prolong recovery.

13. Learning and attention disability • Temporary? • Can be a PERMANENT problem • Improves more quickly with proper management • Complete recovery typically expected

14. Implementing an Accommodation Plan • Individualization • Innovation • Integration/Team work • RN – ATC • Guidance – Teachers • Psychologists – Social Workers • Parents • Fluid situation that will change over time

15. Excused absence from classes • Time out of school/complete rest to start? • Partial attendance as able • Morning fatigue/poor sleep > arrive late • Afternoon fatigue in school > leave early • Selective attendance? • Core classes vs. electives? • Avoid classes that are too challenging?

16. Rest periods during the school day • School nurse’s office • Rest before symptoms become too intense • Take Tylenol/Advil, etc. as recommended by doctor • Return to classes if feeling better • Early dismissal if rest does not help sx

17. Extension of assignment deadlines! • Homework, papers, projects • According to student’s capacity • Removes major source of pressure • Allows student to prioritize sleep & rest!

18. Excuse from some assignments ? • More common in lower grades • Less catch-up to do during/after recovery • Consolidate work into more manageable units • Allow independent work with alternative ways to submit

19. Postpone exams Until student is able to prepare and symptoms are under better control Avoid high stakes testing (e.g. AP exams, SAT) while symptomatic Extended time (x1.5 or x2) until recovered Spring injuries - wait until summer to complete course work and exams? Evaluate true necessity of exam/quiz for student assessment- ? Alternative format

20. Light/noisesensitivity • Excuse from assemblies • Able to eat lunch away from cafeteria • Cap and/or sunglasses for light sensitivity • Avoid fluorescent lights, windows • Limit iPod, TV, computer exposure based on symptoms • Limit texting • Adapt music to what is comfortable

21. NO sports, gym, music/theater/dance • Use time for rest & homework • Short practice visits to stay connected to team • DO NOT ride bus to away games with team • DO NOT sit on bench during games • In stands with family if symptoms allow • Prom

22. Limit other forms of physical exertion Heavy backpacks Climbing stairs Walking home from school/bus stop Caring for large animals, or walking the dog Operating heavy equipment DRIVING Be aware of impaired judgement/ability to react to dangerous situations

23. Academic Care Team • Athletic Trainer • Monitoring of symptoms • Periodic neurocognitive testing • School Nurse • Daily clinical evaluations • Rest & recovery area • Medication • Guidance counselor • Coordinates academic accommodations

24. Teachers • Adjust work according to changing status • Reassurance • Be careful of pressure • Psychologists • Specific input for LD-ADHD students • Social Workers • Adjustment support - especially in longer recoveries

25. Need clear team leader through whom all information flows • Hold the medical team to a standard of communication • Forms to complete/care plan to communicate • Feedback to medical re. symptoms, performance • Have clear policies in place to deal with parents who do shop around, “I’ll sign and take responsibility” • Policies in place for 504 Plan for mTBI • Academics must have priority

26. Beware of and protect from • Pressure from coaches (any kind) • “be there to support the team” “faking it” • Family • “when I played football” “we have a lot invested” • “just trying to get out of…” “my uncle is an EMT…” • ?Friends and/or teammates • “faking it” “we lost because you were out” • Cyber bullying • Loss of social life if witheld from group activity

27. Resources for education • www.cdc.gov/concussion • www.impacttest.com • www.sportsconcussion.net • www.sportslegacy.org

28. Questions?