matthew hall, d.o. assistant professor, sports medicine director, uconn sports concussion program...
TRANSCRIPT
RETURN TO LEARN AFTER CONCUSSION
Matthew Hall, D.O.
Assistant Professor, Sports Medicine
Director, UConn Sports Concussion Program
Medical Director, UConn Club Sports
UConn Health, Dept. of Orthopedics
New England Musculoskeletal Institute
Objectives
Recent evidence on cognitive rest in treatment of concussions.
Review “best practices” and guidelines regarding return to learn.
Discuss school adjustments and accommodations for students with concussion
Return to Learning
“Majority of the focus on concussions has been centered on diagnosis, education of key stakeholders regarding the problem, and the timing of safe return to play” (Halstead et al.)
No standardized guidelines, guidelines based on “expert opinion”
Determined by the health care provider
Individualized treatment plan
Return to Learn
No consensus guidelines Neurocognitive deficits may persistent
despite being asymptomatic Students with increased symptoms with
school may require :○ Reduced work load○ Extended test-taking time○ Days off from school○ Shortened school days
AAP Recommended Approach
Return to learn if able to tolerate light mental exertion for 30 minutes
Standard class/period lengths 30-45 minutes in length
Short periods of rest between classes may be necessary vs. dismissal when symptomatic
Cognitive Rest
Accepted practice & treatment for concussion
What is the evidence for cognitive rest as a treatment for concussion?
How much cognitive rest is enough?
How do you define cognitive rest?
Definition of Cognitive Rest (Moser et al.)
Time off from school No homework No reading No visually stimulating activities No exercise No social visits Increased rest & sleep
Studies on Cognitive Rest
Moser et al. Efficacy of Immediate and Delayed Cognitive Rest for Treatment of Sports-related Concussion. The Journal of Pediatrics (2012)
Retrospective cohort (N = 49)Prescribed cognitive restAll had improved ImPact scores with restEven those with prolonged symptoms still
showed improvement with rest
Studies on Cognitive Rest
Gibson et al. The Effect of Recommending Cognitive Rest on Recovery from Sports-related Concussion. Brain Injury (2013)
Retrospective chart review (N = 135)Primary outcome = duration of post-concussive
symptomsLooked to see if cognitive rest was within the
provider’s plan in the medical recordNo associated between length of symptoms and
whether or not cognitive rest was prescribed
Studies on Cognitive Rest
Brown et al. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Pediatrics (2014)
Prospective Cohort (N = 335)Primary outcome = duration of symptoms
associated with “cognitive activity-days”Cognitive activity-days = average cognitive
activity level x days between visitsPatients self-reports their cognitive activity level
Brown et al. Cognitive Scale
Duration of symptoms by quartile of cognitive activity-days.
Brown N J et al. Pediatrics 2014;133:e299-e304
©2014 by American Academy of Pediatrics
How to “prescribe” cognitive rest?
Relative cognitive rest, not “bubble” therapy
Avoid noisy public locations i.e. restaurants Limit screen time No headphones Short periods of an activity i.e. reading
Start with less strenuous i.e. magazine and not AP homework
Symptoms increasing? Stop, rest, and remember the threshold
School Considerations
Consider each student-athletes needs
Include detailed school note regarding accommodations and adjustments
Difficult cases may require discussion with school or more of a multi-disciplinary approach
Team Approach
Communication between school, physician, and athletic trainerChallenge! Particularly in the office
setting…Need to abide by FERPA & HIPAA
Multi-disciplinary team necessary for prolonged symptoms and post-concussive syndrome
Adjustments vs. Accommodations (Halstead et al.)
“Adjustments”Initial recovery period, first 1-3 weeksNo formal change to student school
environment
“Accommodations”Symptoms > 3 weeksStandardized test changes, extended time
for tests & assignments, schedule changesFormalized with a 504 plan
504 Plan
From Section 504 of Rehabilitation Act and Americans with Disability Act
Students who require accommodations because of a medical diagnosis but do not qualify for an IEP
Can be requested by provider
Individualized Education Plan (IEP)
Allows for “modification” to students education and dictates what services should be provided to the student
Protected under the Individuals with Disabilities Education Act
Testing to determine if student requires and IEP can be requested by the family or the school
History Considerations
Learning disability? Multiple concussions? Concussion with prolonged symptoms? Immediately removed from sport? Depression or anxiety? Mood Disorder? Migraines? Family stressors? School pressures or testing?
My Practice Primarily high school age Out of school for 3-4 days, using the
calendar to my advantage Try to integrate back to school as soon as
possible Detailed school note Start as half days if can tolerate, early on
more about getting them back to their routine Progress to full days as able to tolerate Follow-ups early and often
What can we do better?
Communication with schools:School nurses and/or ATC to help monitor and
manage symptomsCounselor or psychologist to help the
accommodations and transitioning to full time school
• Education and awareness for providers seeing concussions, better guidelines to aid in return to learn Individualized “return to learn” plan
References Harmon KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring
SA,Kutcher JS, Pana A, Putukian M, Roberts WO. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013 Jan;47(1):15-26.
Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K; Council on Sports Medicine and Fitness; Council on School Health. Returning to learning following a concussion. Pediatrics. 2013 Nov;132(5):948-57.
Gibson S, Nigrovic LE, O'Brien M, Meehan WP 3rd. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj. 2013;27(7-8):839-42.
Moser RS, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. J Pediatr. 2012 Nov;161(5):922-6.
Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP 3rd. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014 Feb;133(2):e299-304.
Majerske CW, Mihalik JP, Ren D, Collins MW, Reddy CC, Lovell MR, Wagner AK. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008 May-Jun;43(3):265-74.