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Treatment – Return to Learn Protocol

2. Light Cognitive Activity

•Starts once had significant improvement in symptoms at rest

•Reintroduce in 5-15 minute blocks – television, music, computer time, texting, homework, reading

•Stop the activity if moderate symptoms develop

•Increase repetition and duration if symptoms do not worsen or resolve with a 30 minute break

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Treatment – Return to Learn Protocol

• 3. School Specific Activity

• Homework in 15-30 minutes increments with breaks for 1-2 hours

• If symptoms do not return:

– Decrease the length of the break time

– Gradually increase the time to 30-45 minutes increments for up to a total of 3-4 hours

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Treatment – Return to Learn Protocol

• 4. Return to school

• Half day: Able to do 2 hours of homework at home without symptoms for 1 to 2 days

• Full day: Able to do 3 to 4 hours of homework without symptoms at home

for 1 to 2 days

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School Re-Entry

• Reintegration into school occurs gradually

• Develop symptoms – Lie down in a quiet area supervised

area until the symptoms resolve– If symptoms do not resolve with

break, do not return to class, more recovery time is needed

– If symptoms occur again in the next period, after resting, they should go home

• Upon return to school, hold back on “make up” work

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Acute Concussion Evaluation (ACE) from CDC “Heads Up: Brain Injury in Your Practice”

• Until you (or your child) have fully recovered, the following supports are recommended: (check all that apply)

• __No return to school. Return on (date)• X Return to school with following supports. Review on (date)• X Shortened day. Recommend 3 hours per day until (date) 1• __Shortened classes (i.e., rest breaks during classes). Maximum class length:

_____ minutes.• X Allow extra time to complete coursework/assignments and tests.• X Lessen homework load by 50 %. Maximum length of nightly homework: 30

minutes.• X No significant classroom or standardized testing at this time.• X Check for the return of symptoms when doing activities that require a lot of

attention or concentration.• X Take rest breaks during the day as needed.• __Request meeting of 504 or School Management Team to discuss this plan

and needed supports.

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Missing accommodations on the ACE

• Reduce cognitively demanding tasks

– No more than 1 test/quiz each day

• Allow access to a peer’s or teacher’s notes

– Vestibular-ocular motor impairment

• No gym class

– No writing papers in substitution for gym class

– No watching gym class on the sidelines

• Early dismissal from class to avoid crowded hallways

• Make-up work

– No make-up work until they can handle the current work

– Should not be expected to do all work completed in absence

– Completed over 3-4 weeks

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Symptoms parents and school personnel should watch for

• Increased problems – Paying attention

– Concentrating

– Remembering or learning new information

• Longer time needed to complete assignments• Greater irritability• Less able to cope with stress• Symptoms worsen (e.g., headache, tiredness)

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Return-To-Play

• Decision has 4 hallmarks– Resolution of symptoms

– Neurocognitive recovery

– Asymptomatic with cognitive exertion

– Asymptomatic with physical exertion

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Are Athletes Not Aware of Concussion Symptoms ?

• 1,532 varsity football players from 20 high schools in the Milwaukee, area were retrospectively surveyed

• 29.9% reported a previous history of concussion• 15.3% concussed during the current football season• Only 47.3% reported their current injury

• Why not reported 66% not thinking the injury was serious enough 41% didn’t want to be withheld from competition 36% lack of awareness of probable concussion

McCrea et al. 2004

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Reliance on patients’ self-reported symptoms after concussion may result in under diagnosis of concussion.

This may lead to premature return to play.

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Neurocognitive Recovery

• Children often having an extended period of neurocognitive recovery

• High School athletes– Average duration of neurocognitive deficits is

7-14 days

• College athletes– Average duration of neurocognitive deficits is less

than 48 hrs

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Do Symptoms Correlate with Neurocognitive Recovery?

• Neurocognitive deficits may persist even when physical symptoms have reportedly resolved

• A prospective case–control study of high school athletes with mild concussions (Lovell 2003)– Reported that their post-concussion symptoms had

resolved by day 4 post-injury.

– Significantly lower memory scores 7 days post-injury compared with their baseline scores

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Return-To-Play

• Decision has 4 hallmarks– Asymptomatic at rest

– Asymptomatic with cognitive exertion

– Neurocognitive recovery

– Asymptomatic with physical exertion (Graduated Return to Play Protocol)

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Graduated Return to Play Protocol

Rehabilitation stageFunctional exercise at each stage of rehabilitation Objective of each stage

1. No activity

full day of normal cognitive activities (school day, studying for tests, watching practice, interacting with peers) Recovery

2. Light aerobic exerciseWalking, swimming or stationary cycling keeping intensity, 70% maximum predicted heart rate Increase Heart Rate

3. Sport-specific exerciseSkating drills in ice hockey, running drills in soccer. No head impact activities Add Movement

4. Non-contact training drills

Progression to more complex training drills, eg passing drills in football and ice hockey; may start progressive resistance training

Exercise, coordination, and cognitive load

5. Full contact practiceFollowing medical clearance** participate in normal training activities

Restore confidence and assess functional skills

6. Return to play Normal game play  

• If no return of symptoms the next day advance• If return of symptoms drop back to the previous level of activity that caused no symptoms•**Consultation between school health care personnel, i.e, Licensed Athletic Trainer, School/Team Physician, School Nurse and student-athlete’s physician

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Return to Play in Children

• Decisions should be made cautiously • Decisions should be individualized• No evidence based RTP guidelines that

have been validated in children• Limited data on the acute and long-term

consequences in children aged 5-12 years

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Take home points

• Concussion = Mild Traumatic Brain Injury

• Metabolic mismatch during healing phase

• Need to return to learn and return to play in a graded fashion

• School attendance and activities need to be modified

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Take home points

• Repeat injury during healing phase may lead to prolonged or permanent symptoms

• Compared to adults, pediatric brains heal slower and are at risk for more severe injuries

• Return to play in a graded fashion• Athletes, parents, coaches must be educated about

the signs, symptoms, and treatment of concussions • Need to emphasize the serious consequences of

ignoring concussion symptoms to athletes

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Concussion: Education

• Resources:– http://www.chop.edu/servi

ce/concussion-care-for-kids/home.html

– http://www.cdc.gov/ConcussionInYouthSports/

– http://www.nata.org/

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References

• Guskiewicz KM et al. Epidemiology of Concussion in Collegiate and High School Football Players. AJSM 2000; 28:643-650

• Field M et al. Does Age Play a Role in Recovery from Sports-Related Concussion: A comparison of High School and Collegiate Athletes. J Pediatrics 2003; 142: 546-553

• Kaut KP et al. Reports of Head Injury and Symptom Knowledge Among College Athletes: Implications for Assessment and Educational Intervention. Clin J Sport Med 2003; 13:213-221

• Grindel SH et al. The Assessment of Sport-Related Concussion: The Evidence Behind Neuropsychological Testing and Management. Clin J Sport Med 2001; 11:134-143

• Lovell MR et al. Recovery from mild concussion in high school athletes. J Neurosurg 2003; 98:296-301

• McCrea M et al. Unreported Concussion in High School Football Players Implications for Prevention Clin J Sport Med 2004; 14:13-17

• Iverson G et al. No cumulative effects for one or two previous concussions. Br J Sports Med 2006; 40:72-75

• Iverson G et al. Predicting Slow Recovery from Sport-Related Concussion: The New Simple-Complex Distinction. Clin J Sport Med 2007;17:31-37

• Collins MW et al. On-Field Predictors of Neuropsychological and Symptom Deficit Following Sports-related Concussion. Clin J Sport Med 2003; 13:222-229.

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References

• Kirkwood MW et al. Pediatric Sport-Related Concussion: A Review of the Clinical Management of an Oft-Neglected Population. Pediatrics 2006; 117”1359-1370.

• McCrea M. Acute Effects and Recovery Time Following Concussion in Collegiate Football Players The NCAA Concussion Study. JAMA 2003; 290:2556-2563.

• Van Kampen DA et al. The “Value Added” of Neurocognitive Testing after Sports-Related Concussion. Am J Sport Med 2006; 34:1630-1635.

• Lovell M. Return to play following Sports-Related Concussion. Clin Sports Med 2004; 23:421-441.

• McCrory P et al. Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin Sports Med 2005; 15:48-55.

• Valovich McLeod TC et al. Identification of Sport and Recreational Activity Concussion History through the Preparticipation Screening and a Symptom Survey in Young Athletes

• Asplund CA et al. Sport-Related Concussion Factors Associated with Prolonged Return to Play CJSM 2004

• Guskiewicz KM et al. Cumulative Effects Associated with Recurrent Concussion in Collegiate Football Players The NCAA Concussion Study. JAMA 2003; 2549-2555

• Delaney JS et al. Concussions Among University Football and Soccer Players. Clin J Sport Med 2002; 12:331-338

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References

• McCrory P et al. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008. Clin J Sport Med 2009; 19:185-200

• Purcell L. What are the most appropriate return-to-play guidelines for concussed child athletes? Br J Sport Med 2009; 43 (suppl I):i51-i55

• Cantu RC. When to Disqualify an Athlete After a Concussion. Current Sports Medicine Reports 2009; 8:6-7

• Reddy CC and Collins MW. Sports Concussion: Management and Predictors of Outcome 2009; Current Sports Medicine Reports 2009; 8:10-15

• Benson BW et al. Is protective equipment useful in preventing concussion? A systematic review of the literature. Br. J. Sports Med. 2009;43;i56-i67

• Makdissi M. Is the simple versus complex classification of concussion a valid and useful differentiation? Br. J. Sports Med. 2009;43;i23-i27

• Dick RW. Is there a gender difference in concussion incidence and outcomes? Br. J. Sports Med. 2009;43;i46-i50

• Gioia GA et al. Which symptom assessments and approaches are uniquely appropriate for paediatric concussion? Br. J. Sports Med. 2009;43;i13-i22

• Meehan III WP et al. Sport-Related Concussion. Pediatrics 2009;123:114–123

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Protective Equipment

• There is evidence that helmet use reduces head injury risk in skiing, snowboarding and bicycling, but the effect on concussion risk is inconclusive.

• No strong evidence exists for the use of mouthguards or face shields to reduce concussion risk.

• Evidence is provided to suggest that full facial protection in ice hockey may reduce concussion severity, as measured by time loss from competition.

• Headgear use effect on concussion risk is inconclusive in soccer

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ImPACT

• 11 years and older• Postconcussion Symptom Scale (22 items)• 6 modules

– Word Memory, Design Memory, X’s and O’s, Symbol Match, Color Match, Three Letters

• Composite Scores– Verbal memory, Visual memory, Reaction

time, Visual motor processing speed

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CONCUSSION SYMPTOMSCONCUSSION SYMPTOMS

HEADACHE

11 2 3 4 5 6 2 3 4 5 6

Not experiencing symptom

Severe

Click on the button that indicates the severity of your symptoms

Minor

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X’S AND O’S (Working Memory)

X

X

X

X

X

X

XX

X

Remember the location of the highlightedsymbols

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VISUAL MEMORY DISTRACTOR

Click the left mouse button if you see this

Click the right mouse buttonif you see this

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X’S AND O’S (Working Memory)

X

X

X

X

X

X

XX

X

Click the symbols that was highlighted

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1 2 3 4 5 6 7 8 9

SYMBOL MATCH

Click on the number thatgoes with this symbol.

Pay close attention becausethe key will disappear at sometime during the test

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1 2 3 4 5 6 7 8 9

SYMBOL MATCH-MEMORY

Click on the number thatgoes with this symbol

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Neurocognitive Testing

• ImPACT predictors for slower recovery– The more abnormal composite scores the more

severe the concussion (Van Kampen 2006)

– Athletes with complex concussions who were slow to recover were 18 times more likely to have 3 unusually low neuropsychological test scores than those with simple concussions (Iverson 2007)