1 Post-Concussion: More than Return to PlayMinnesota Brain Injury Alliance Annual Professional Conference April 21, / Brooklyn Center, MN Leslie Seymour, MD MPH * Anna Gaichas, MS Jon Roesler, MS * Mark Kinde MPH

2 Objectives 1) Understand the magnitude of the problem2)Understand the impact concussion can have on learning. 2) Understand accommodations that can be made by the school.

3 Concussion “Any trauma induced alteration in mental status that may or may not include a loss of consciousness” * * American Academy of Neurology American Academy of Neurology definition Our case inclusion criteria: Any 7th – 12th grader who suffered a concussion while participating in a school sponsored MSHSL athletic event.

4 What is a Concussion? A concussion can occur when a bump or blow to the head or hit to the body causes movement of the brain inside the skull The brain can move back and forth or twist within the skull… Added CAN in first sentence Also changed last statement from: The brain moves back and forth or can twist within the skull https://youtu.be/9myOgFttBMg

5 What is a Concussion?, continuedMovement may stretch and damage brain cells, creating chemical changes in the brain Chemical changes can result in slowing down of brain activity... can worsen over time Outcomes can vary greatly, depending on gender, age, location of impact, force Added ? To title Changed create to creating Switched order of last 2 bullets Still don’t understand: can worsen over time Removed “of impact” after Outcomes in last statement. Also suggest changing this statement to the following: Many factors; gender, age, location of impact, force; can determine whether a concussion occurs, and it’s severity if one does.

6 Diagnosis of concussionNo general consensus Of course there is not anything set in stone or published yet, but many of the researchers recommended and challenged providers to begin moving away from diagnosing concussion only based on symptoms, but also on neurological findings that research is beginning to show are consistent with a concussive injury, including the visual motor deficits (poor convergence, accommodation and saccades/smooth pursuit eye movement), cervical spine findings (whiplash) that often accompanies concussion, balance difficulty (abnormal Romberg, tandem walking or BESS testing), vestibular difficulty and/or autonomic dysfunction (abnormally high heart rates and blood pressures at rest and with mild physical activity). Dr. Leddy has done a lot of the research on this and would be a good resource to read.  He has multiple publications as main author and co-contributor.

7 Hospitalized Concussion

8 ED Treated Concussion

9 What about out-patient?Clinic, Urgent Care…

10 Minnesota’s APCD Includes most payers of medical claims.It incorporates data from Medicaid and Medicare as well as from commercial payers – thus permitting a rich and systematic analysis of health care delivery for the state. Minnesota one of few states that also include claims from self-insured employers, making the data uniquely comprehensive and complete.

11 Out-patient Concussion

12 Focusing on youth

13 Return to... Return to Learn: Returning to school with full homework load and no accommodations Return to Play: Returning to prior level of physical activity including return to gym and/or return to sport I don’ thinik this slide is needed. Think it actulaly makes this more confusing. If we keep it, would suggest that the GOAL of returning to learn is to return with full homework and no accom, but that it can take time to get there.

14 Return to Learn OverviewRest & Planning Return gradually with support Slowly work up to full time and full workload Return to physical activities Mary’s resource from Nationwide Children’s Moved this back here. We had it at end of section and I think it’s better here. Good overview. Also changed school to learn in title

15 Email: [email protected]THANKS! Contact Information Leslie Seymour, MD, MPH Phone:

16 Presented by… A consortium of public and medical agencies who provide information, resources and support to the families of children and youth who experience concussion

17 Concussion Signs Loss of consciousness (rare in concussion/mild TBI)Dazed or stunned Confusion, forgets events before and after impact, difficulty with daily routines Memory loss of events surrounding the injury Slow to respond to questions Changed all to concussion signs & symptoms. Should discuss that some are immediate, some can be more delayed. Also some are observed and some are reported.

18 Concussion Symptoms Headache/pressure in the headSleep problems (too much or too little) Fatigued, sluggish, groggy Nausea/Vomiting Dizziness Balance difficulty

19 Concussion Signs & Symptoms, continuedSensitivity to light/noise Visual changes (difficulty focusing or double vision) Tinnitus (ringing in the ears) Difficulty remembering or concentrating May feel irritable, anxious or depressed Made changes

20 Concussion Symptoms, continuedSymptoms can be immediate or delayed (up to 24 to 48 hours after injury) Some symptoms may go unnoticed until certain demands are placed (i.e. reading in class) Delay in recognizing or experiencing symptoms can result in child returning to play or school immediately after injury... followed by abrupt increase in symptoms Added 2nd bullet

21 Concussion Symptoms, continuedSeverity of the impact doesn’t always correlate with the severity of symptoms Symptoms often resolve over days; however, recovery can be prolonged (weeks to months) Wonder if we want to adjust this timeline. Refer to CDC mild TBI Guidelines (just out in draft form)

22 Second Impact SyndromeSecond concussion sustained prior to complete healing of the initial concussion The healing brain is more vulnerable Outcomes are typically more severe than the initial injury Can result in coma or death Bullet 2-May be more affected by lesser blow or more significant symptoms Bullet 4: Although this is rare

23 Initial Concussion CareRemove immediately from physical & cognitive activity Assess for concussion symptoms & other injuries Gather injury information and document Contact parent/guardian Reevaluate after a period of rest and determine next steps WHEN IN DOUBT - SIT THEM OUT! I moved this slide. It was initially after the emergency care but I thought it was a better intro. Added second bullet Removed this from the end: perhaps it can just be verbal for now (Includes recess, physical education class or extracurricular sports and/or activities after school the same day) Parent/guardian- ensure person to person contact

24 After a Concussion has occurred…Gather information from family (medical documentation if available) Notify school personnel (Concussion Care Team) Identify a plan for return to school Disseminate information to teachers and staff Communication between family and school may not happen automatically...may need to initiate follow-up if aware of injury Changed title from: Upon learning about the injury... (this sounds a little weird if the injury did occur at school) Changed order, gather info 1st instead of 2nd. Also took out “about injury” Bullet 2: release may be needed

25 Roles of Concussion Care TeamIdentify points of contact within your school for: Communicating with family, external providers and school team Monitoring and documenting symptoms Implementing and monitoring academic supports Identify student’s contact person in school Don’t forget to involve student & discuss their role Primary contact- receives, seeks clarification and disseminates info, obtains releases monitoring/doc- may have a back-up that student has prior relationship with May be one person or several; when different people involved, ensure that entire team is included in all communication so no one is missed Examples: School nurse, counselor, social worker, teacher, athletic trainer; decide how often, what time, where

26 A Concussion Plan Goal: To get student back to previous activities, supported with proper accommodations to manage symptoms. When to Return School contacts Specific accommodations Timelines Removed “developing” from start of title Added when to return since that’s what we discuss as part of the plan first

27 Sample Concussion PlanIn the real world, concussion plan may need to be broadly developed, then fine-tuned after student returns to school... I moved this here, it was one slide later (after When to Return to School)

28 When to Return to SchoolExtended time away from school after a concussion is rarely recommended Factors to consider for return timeline: Symptom severity Other injuries How much school has already been missed Home environment Return to school may include partial days as tolerated Add literature citations here to support return to school; Home schooling not recommended Discuss how return to school schedule may vary, 1-2 hours or half days to start, increasing as tolerated over time as symptoms resolve Added “after a concussion” in first statement

29 Examples of Accommodations for ConcussionShorter school days Frequent breaks in quiet area - scheduled and as needed Open hours/study halls Avoid over-stimulating environments Alternative passing times Modify test format or setting Sensory accommodations - visual, vestibular, auditory Include examples of sensory accommodations, comment on visual difficulties and use of screens, lights, wearing hat with brim, tinted eyeglasses, etc Changed title from: General Accommodations: A Few Examples Added school to 1st bullet

30 Examples of Accommodations for Concussion, continuedDrop or delay some classes Adjust assignment length/homework Consider pass/fail or alternate grading system No physical education classes or recess Consider no music class/band No/reduced extra-curricular activities Consider alternate transportation to/from school May need to develop alternate plan to make up some credits Title

31 Communication Communicate concussion plan with team members:Student/Family Academic Team (Teachers, Nurse, Guidance Counselor, Administrators, Social Worker, Phy Ed teacher) Athletic Team (Coach) Medical Team (Primary Care Provider or Concussion Specialist, Athletic Trainer, Rehab team, Psychology) Don’t use term concussion team here Should Athletic Trainer be part of Medical Team or Athletic Team?

32 Emotional Toll Consider emotional and social impact of injury and recovery Isolation from peers Impact on identity Restricted from preferred activities Academic stressors Risk of depression, anxiety which can be exacerbated by missing school, falling behind

33 Challenges... “But they look fine…” Symptoms - variable & individualInformation from medical providers Communication with family Pre-injury factors No one plan fits all; if you have seen one concussion, you have only seen one concussion! Info from providers: too much vs none at all. May be different from different providers/clinics Pre-injury factors: just because a child wasn’t a strong student before the injury doesn’t mean they don’t deserve the same accommodations post injury. Also high achieving students who may need encouragement to use accommodations (rather than as needed) Moved this slide so it’s after Emotional Toll. Also took Additional out of title

34 Keep in Mind Accommodations may be needed for days to monthsShould be agreed upon by parents, school staff, medical providers, and student Monitor progress and document As symptoms decrease, supports can be removed gradually No return to activity until cleared Return to activity covered later Added accommodaitons to 2nd bullet

35 School Team In addition to the student and family, the concussion care team in the school could consist of many multidisciplinary members PE teacher is critical classroom teacher, as are homeroom teachers Removed “their” before family Seems we already went over this. Is this needed?

36 In addition to the student and family, the concussion care team in the school could consist of many multidisciplinary members… School nurse Speech therapist 504 coordinator or counselor School psychologist Classroom teacher Special education teacher Athletic trainer Coaches Physical therapist Occupational therapist Administrator District TBI specialist Social worker

37 Spectrum of Supports: Overlapping Domains In the School SettingEXAMPLES for each area of diagram: General Education: All students 504 Eligible: Student has a disability (concussion), but it does not substantially limit a major life activity (concussion symptoms recover within a brief span of time) 504 Plan: Student with disability (concussion with chronic symptoms) that is impacting one or more major life activities; accommodations are needed IDEA: Student with a potentially chronic/long term disability (e.g., post-concussion syndrome), requiring modifications to instruction/curriculum and in need of special education services (IEP)

38 Section 504 Federal anti-discrimination lawProtects rights of individuals with disabilities in programs/activities that receive federal financial assistance from US Dept. of Education (schools) Is a LEGAL document Discuss range in how schools utilize 504 plans Qualification for 504 Plan Must have documented disability Substantially limits one or more major life activities

39 When to Consider an Evaluation & 504 PlanWhen symptoms don’t resolve after 4-6 weeks, or worsen with increased activity When new symptoms occur over time When a concussion plan doesn’t provide enough support When there’s increased need for documentation Mention post-concussion syndrome, also a reason to consider a 504 (implies longer lasting symptoms) To last bullet, what’s an example. When is there an increased need for documentation?

40 CDC Concussion Signs & Symptoms ChecklistEvaluates: Observed signs Physical Symptoms Cognitive Symptoms Emotional Symptoms https://stacks.cdc.gov/view/cdc/12353/

41 CDC: ACE Care Plan Acute Concussion Evaluation (ACE): School VersionReturning to School ADL’s Academic accommodations Return to sports and activities Added title: CDC Care Plan

42 CDC Fact Sheets: School Nurses, Parents, Educators, CoachesHeads Up to Schools: Know Your Concussion ABCs A—Assess the situation B—Be alert for signs and symptoms C—Contact a healthcare professional

43 Computerized Cognitive TestingImPACT neurocognitive testing Moved this so it’s not the 1st resource.

44 State & Local Resources (alpha order)Children’s Hospitals & Clinics of Minnesota Gillette Children’s Specialty Healthcare Hennepin County Medical Center: Pediatric Brain Injury Program

45 State & Local Resources, continuedMN Brain Injury Alliance Mayo Clinic (search ‘concussion’) MN Low Incidence Projects Minnesota Athletic Trainers Association (ADD AGENCIES & LINKS HERE)

46 Additional Resources National Athletic Trainers Association REAP program (Remove/Reduce, Educate, Adjust/Accommodate, Pace) NASN Concussion Position Statement https://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/smid/824/ArticleID/218/Default.aspx (ADD AGENCIES & LINKS HERE)

47 Additional Resources, continuedThe Center on Brain Injury Research & Training MN Department of Education (do they have TBI info) MN State High School League Protocol Any school nurse resources? (ADD AGENCIES & LINKS HERE) Added last 3 suggestions

48 Electronic Resources Centers for Disease Control & Prevention: Concussion Brainline Get Schooled on Concussions (ADD SOURCES/LINKS HERE)

49 This presentation was developed by the following agency partners (alpha order):Children’s Hospitals and Clinics of Minnesota Gillette Children’s Specialty Healthcare Hennepin County Medical Center Minnesota Athletic Trainer’s Association Minnesota Department of Health Minnesota Low Incidence Projects Added HCMC logo