Schooling concussion: Return to learn for the student athlete. Alex M. Taylor, PsyD Neuropsychologist Brain Injury Center

Transcription

1 Schooling concussion: Return to learn for the student athlete Alex M. Taylor, PsyD Neuropsychologist Brain Injury Center

2 Objectives Developing brain Response to injury Neurocognitive/ academic/ contextual considerations School based management framework

3 Developing brain Brain water content, cerebral blood volume, myelination, skull geometry, and suture elasticity are related to maturation

4 Developing brain Brain not fully developed until ~25 yrs Brain needs time & experience to mature Child s brain not well organized & undifferentiated

5 Developing brain Casey et al., 2005

6 Response to injury Plasticity Early insult may have impact on later development Greater secondary consequences Social/academic progress Capacities in process of development or not yet developed are particularly vulnerable to brain injury

7 Skills Skills Response to injury Established skills To be acquired skills Time Time Norm TBI Norm TBI

8 % of Group Learning difficulty following TBI 60% 50% 40% 30% 20% 10% 0% Prior to injury 6-month 12-month Extended Time Severe Moderate ORTHO n = 134 Taylor et al., 2003

9 Concussion

10 PCSS Natural history of concussion % recover within days Acute management risk of repeat injury & prolonged symptoms Typical Recovery Pre-Injury Pre-injury Day 1 Day 3 Day 14 3 Months months

11 Vulnerable neurocognitive skills Decreased NP functioning in concussed athletes Attention / concentration Working memory (online memory) New learning & memory storage / retrieval Speed of processing information Reaction time

12 Learning difficulty following concussion Symptom/ Problem Elementary Middle High School Headaches Inattention Fatigue Comprehension Difficulty studying n = 349 Ransom et al. 2015

13 Case study: concussion

14 Percentile Case study: ImPACT data Time 3/8/ Time 5/19/ Time 8/2/ Verbal Memory Visual Memory Processing Speed Reaction Time

15 PCSS Case Study: PCSS total symptom score PCSS Faking it College admissions Summer job Playoffs SATs Dad s job Final exams Try outs Prom Day 1 Day 10 Day 21

16 Management guidelines Return to play Symptom free at rest Symptom free with exertion Graded RTP protocol Intact neurocognitive function Return to learn

17 Management Acute (injury-3 days) Post-acute (4-28 days ) Prolonged (>28 days)

18 Acute School Athletic Youth Family -Consult around when student should return to school -Remove from sports -Developmentally appropriate education, advice, and reassurance about mtbi -Ensure that caregivers can identify and act on neurological emergencies -Consider full rest with high initial symptom burden -Ensure that school is alerted to the injury and monitors for neurological deterioration -SLEEP -HYDRATION -Provide parent-focused education, advice, and reassurance about mtbi -Attend to caregiver anxiety Adapted from Kirkwood et al., 2008

19 Acute: reduce exertional effects Metabolic mismatch Exertional effects Classroom / school: demands on the brain Exacerbates metabolic mismatch and diverts resources necessary for cellular repair away from injured cells Treatment = sensible rest

20 Acute: overdosing cognitive rest? Utility of full rest > 3 days questionable (Silverberg & Iverson et al., 2012) Prolonged/ elevated symptoms in patients prescribed 5 days of rest following concussion (Thomas et al., 2014) Considerations Standard school year = 180 days 2-week absence = 5% school year or 22% qtr 37% of CPS students who missed 5-9 days of school did not graduate in 4yrs (Allensworth & Easton, 2007)

21 Acute: initial accommodations Rest breaks Quiet room Early dismissal Class exemptions (e.g., band) Sun glasses Physical Cognitive Reduce / adjust Class notes Assistive technology Alternative testing Audit / tutoring Emotional Sleep/Energy Support / guidance Safe signals Monitor mood Rest breaks Late arrival Early dismissal

22 Post-acute School Athletic Youth Family -Adjust accommodations to increase cognitive demand, as tolerated -Assess emotional toll restriction from sports may be having -Psychoeducational consultation as needed, including reassurance and reasonable symptom attributions -Recommend behavioral prescriptions as needed -Provide ongoing education and advice about symptoms -Emphasize preventing further injury while youth is still recovering

23 Prolonged School Athletic Youth Family -Coordinate school-based services among educators and healthcare personnel -504 plan (accommodations) -IEP (specialized instruction) -Ensure individualized cost benefit analysis conducted when considering return to play -Keep in mind persistent symptoms often at least partially reflect noninjury related factors -Consider cognitive behavioral therapy, focused on functional improvement -Reframe search for cure and help child develop more effective coping strategies -Explore post-injury family dynamics and consider family problemsolving therapy as needed -Consider non-injury related factors when developing educational plans Adapted from Kirkwood et al., 2008

24 Risks for prolonged recovery Acute markers Initial symptom score likely best predictor Prolonged LOC / amnesia Multiple collisions / contact prior to removal from play Premorbid considerations Prior concussion Psychological adjustment ADHD / LD Migraine Contextual factors

25 Risk: history of concussion Cumulative effect lowered threshold with additional injury increased vulnerability greater acute symptoms, including neurocognitive deficits potential for longer recovery times

26 Risk: psychological adjustment Psychological adjustment Pre-existing affective symptomatology potentially exacerbated Emotional or behavioral symptoms may be the direct result of the head injury OR a result of adjustment to injured status

27 Risk: neurodevelopmental disorder Attention deficit hyperactivity disorder Learning disability Already working with a vulnerable brain Resource allocation Compensatory strategies unavailable or take longer to be deployed

28 SUMMARY Children are not mini-adults Most children and adolescents recover from concussion within 1-3 weeks, but some take longer Initial treatment involves SENSIBLE rest Individualized, progressive return to learn practices minimize secondary consequence of missed school

29 Suggested readings Kirkwood, M. W., Yeates, K. O., Taylor, H. G., Randolph, C., McCrea, M., & Anderson, V. A. (2008). Management of pediatric mild traumatic brain injury: a neuropsychological review from injury through recovery. The Clinical Neuropsychologist, 22(5), Lovell, M. R., & Fazio, V. (2008). Concussion management in the child and adolescent athlete. Curr Sports Med Rep, 7(1), Master, C. L., Gioia, G. A., Leddy, J. J., & Grady, M. F. (2012). Importance of Return-to-Learn in Pediatric and Adolescent Concussion, (September), 1 6. McGrath, N. (2010). Supporting the student-athlete s return to the classroom after a sport-related concussion. Journal of Athletic Training, 45(5), Meehan, W. P., Mannix, R. C., Stracciolini, A., Elbin, R. J., & Collins, M. W. (2013). Symptom severity predicts prolonged recovery after sport-related concussion, but age and amnesia do not. The Journal of Pediatrics, 163(3), Popoli, D. M., Burns, T. G., Meehan, W. P., & Reisner, A. (2013). CHOA Concussion Consensus: Establishing a Uniform Policy for Academic Accommodations. Clinical Pediatrics. Sady, M., Vaughan, C., & Gioia, G. (2011). School and the concussed youth: recommendations for concussion education and management. Physical Medicine and Rehabilitation. 22(4), 1 17.

30 Thank you Brain Injury Center Boston Children s Hospital & Sports Concussion Clinic Division of Sports Medicine Boston Children s Hospital