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Returning to Learning
Following a Concussion
Mark Halstead, MD, FAAP
St. Louis Children’s Hospital
Cynthia Di Laura Devore, MD, FAAP
Pediatrician Specializing in School Health
Karen McAvoy, PsyD
Rocky Mountain Hospital for Children
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Objectives
 Discuss background and epidemiology of concussions.
 Understand common signs and symptoms of concussion.
 Describe the Return to Learning Team Concept.
 Develop strategies for returning to the classroom following a
concussion.
 Understand how to assist the concussed student with prolonged
symptoms.
 Discuss determining readiness to return to learn.
 Discuss classroom strategies to return to learn, especially related to
specific signs and symptoms.
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Epidemiology: Boys Sports
Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958–
963; Castile L, Collins CL, McIlvain NM, et al. The epidemiology of new versus recurrent sports concussions among high school athletes, 2005-2010. Br J Sports
Med. 2012;46(8):603–610; and Marar M, McIlvain NM, Fields SK, et al. Epidemiology of concussion among United States high school athletes in 20 sports. Am J
Sports Med. 2012;40(40):747–755
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Epidemiology: Girls Sports
Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958–
963; Castile L, Collins CL, McIlvain NM, et al. The epidemiology of new versus recurrent sports concussions among high school athletes, 2005-2010. Br J Sports
Med. 2012;46(8):603–610; and Marar M, McIlvain NM, Fields SK, et al. Epidemiology of concussion among United States high school athletes in 20 sports. Am J
Sports Med. 2012;40(40):747–755
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Concussion Epidemiology
Marar M, McIlvain NM, Fields SK, et al. Epidemiology of concussion among United States high school athletes in 20 sports. Am J Sports Med.
2012;40(40):747–755
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Mechanism of Injury
Gessel LM, Fields SK, Collins CL, et al. Concussion among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495–503
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Common Signs and Symptoms
Physical
Emotional
Headache
Dizziness
Sensitivity to light
Sensitivity to noise
Visual changes (blurry vision; double
vision)
Nausea/vomiting
Fatigue
Irritability
Sadness
More emotional
Nervous/anxious
Cognitive
Sleep
Difficulty remembering
Difficulty concentrating
Feeling slowed down/foggy
Difficulty with clear thinking
Sleeping more than usual
Sleeping less than usual
Trouble falling asleep
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Common Symptoms
Meehan WP 3rd , d’Hemecourt P, Comstock RD, et al. High school concussion in the 2008-2009 academic year: mechanism, symptoms, and management. A J
Sports Med. 2010;38(12):2405–2409; Castile L, Collins CL, McIlvain NM, et al. The epidemiology of new versus recurrent sports concussions among high school
athletes, 2005-2010. Br J Sports Med. 2012;46(8):603–610
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Physical Symptoms
 Headache
o Can distract from concentration
o Can vary throughout days with various triggers
 Dizziness/Lightheadedness
o Can indicate vestibular system injury
o Can be provoked with visual stimulus (video, rapid
movements)
o Standing or walking in crowded environment may be
difficult
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Physical/Cognitive Symptoms
 Visual symptoms
o Can affect ability to watch: videos, slide shows, smart boards, tablets,
computers, artificial lighting
o Difficulty reading and copying
o Difficulty paying attention to visual tasks
 Noise sensitivity
o Can affect ability to be in: lunchroom, noisy hallways, shop classes,
music classes, organized sport practices
 Difficulty remembering/concentrating
o
o
o
o
Test taking
Difficulty recalling or applying previously learned material
Standardized test taking
Driver’s education classes
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Sleep Symptoms
 Sleep Disturbances
o
o
o
o
Excessive fatigue can hamper memory
Can cause tardiness or excessive absences
Sleeping in class
Excessive napping can further affect disrupted sleep cycle
FOR OFFICE USE ONLY
Name _______________ _____________________
DOB _____/_____/_____
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DOS _____/_____/_____ Previous Symptom Score (if available)
________________
IMPORTANT : Please have the PATIENT fill out based on what symptoms they have
had in the LAST 24 hours ONLY. Please ONLY CIRCLE ONE number per symptom
Symptom Checklists
NONE
MILD
MODERATE
SEVERE
Headache
“Pressure in Head”
Neck Pain
Nausea or Vomiting
Dizziness
Blurred Vision
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Sensitive to Light
Sensitive to Noise
Feeling Slowed Down
Feeling “in a fog”
“Don’t feel right”
Difficulty Concentrating
Difficulty Remembering
Fatigue or Low Energy
Confusion
Drowsiness
Trouble Falling Asleep
More Emotional
Irritability
Sadness
Nervous or Anxious
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For Doctor Halstead’s Use Only
10/2013
TSS
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The Return to Learning Team Concept
 Medical team
 Family team
 School teams:
o academic team
o physical activity team
Effect of Concussion on
School Learning &
Performance
Effect of School
Learning & Performance
on Concussion Recovery
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The Role of the Medical Team
 Educate the child or adolescent and family on the nature and
typical course of concussion, and the importance of rest,
cognitive and physical, during recovery.
 Designate an office staff member as the contact person who
can serve as the liaison between the medical home, the
family, and the school, and communicate concerns back to the
pediatrician.
 Verify symptoms that might interfere with learning and
communicate with the school, and reassess the student as
indicated based on family and school feedback.
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The Role of the School Teams
 Allow a student to rest and return to learning at a pace
consistent with recommendations from the medical home,
based on verified signs and symptoms.
 Designate a staff member as the contact person who can
serve as the liaison between the medical home, the family,
and the school, and communicate concerns back to the
pediatrician and parent.
 Report back to family and pediatrician on how the child or
adolescent is managing, and work as a team to advance,
regress, or hold the student steady in his/her return efforts.
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The Role of the Family Team
 Enforce rest and reduce stimulation as prescribed by the
pediatrician.
 Work with the school to develop a plan for return to learning
and sign essential releases to allow communication between
the school and the medical homes.
 Monitor the child for readiness to begin a return to learning
process and keep the medical and school homes updated.
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Guidance for Determining Student Readiness to
Return to Learning
Student tolerance of cognitive stimulation or concentration.
SYMPTOM ONSET
<30-45 minutes
SYMPTOM ONSET
>30-45 minutes
REST AT HOME
Encourage sleep
School Attendance
Light mental activity
Light reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR
SYMPTOM EXACERBATION
30-34 min. of instruction
15 min. rest period
Additional instruction as tolerated
No driving, no employment, no malls,
decreased screen time/social
networks/video games/computer work.
Late start/early dismissal, planned/as needed rests,
increase activity as tolerated, no extracurricular until back
to full curricular program. For missed instruction consider
class notes, easing assignments, reduced course load, etc.
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Tutoring Following Concussion
 Tutoring is almost never indicated:
o In the early phases of recovery
o In-home for concussion alone
 Tutoring may be indicated for a student who cannot tolerate
crowds, but can attend 30-40 min. Yet, the goal should be for the
student to leave the home:
o Work in the school library with teacher after hours
o Avoid passing time in the halls
o Avoid crowded areas, cafeterias, auditoriums, gymnasiums
 Tutoring may be indicated for a student who cannot leave home
for reasons other than concussion, such as a concussion associated
with multiple severe injuries besides a concussion or recovering
from surgery.
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Sample Six Step “Return to Learning” Model Based on
Six Step “Return to Play” Model
 Step 1 Rest and recovery at home without any academics
 Step 2 Light mental activity in quiet environment (30-45 min.)
 Step 3 More sustained mental activity in more stimulating
environments for longer periods and shorter breaks
 Step 4 Increased mental activity in regular school setting with
continued adjustments only as needed
 Step 5 Full day in all academic classes with adjustments as
needed
 Step 6 Regular school attendance full time with no restrictions
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Strategies to Help in the School Setting based
on Symptoms
 Adjustments
 Accommodations
 Modifications
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Academic Adjustments
 Can be implemented immediately
 Are temporary, for up to usually 3 weeks or less
 Are easily adjusted and changed based on need
 Are done at building level by principal and teaching team
 Can address all aspects of instruction except standardized
testing
 Involves General Education
Sign/Symptom
Headache
Dizziness
Light sensitivity
Potential Adjustments in School Setting

Frequent breaks

Identifying aggravators and reducing exposure to them

Rests, planned or as needed, in nurse’s office or quiet area

Allow student to put head down if symptoms worsen

Give student early dismissal from class and extra time to get from class to class to
avoid crowded hallways

Reduce exposure to computers, smart boards, videos

Reduce brightness on the screens

Allow the student to wear a hat or sunglasses in school

Consider use of audio tapes of books

Turn off fluorescent lights as needed
Noise sensitivity
Difficulty with
memory
Sleep problems

Limit or avoid band, choir, or shop classes

Avoid noisy gyms and organized sports practices/games

Consideration of the use of ear plugs

Give student early dismissal from class and extra time to get from class to class
to avoid crowded hallways during pass time

Avoid testing or completion of major projects during recovery when possible

Provide extra time to complete non-standardized tests

Postpone standardized testing (may require that a 504 Plan is in place)

Consider one test per day during exam periods

Consider the use of preprinted notes, note taker, scribe, or reader for oral test
taking

Allow for late start or shortened school day to catch up on sleep

Allow rest breaks
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Summary
 Concussion impacts learning and the stress of learning can impact
concussion recovery.
 A team approach combining point persons to optimize
communication among the medical home, the school home, and the
family home to create an individualized re-entry plan is vital.
 The medical team substantiates medical need and identifies signs
and symptoms; the family team reinforces rest and
determines/monitors readiness to return to learning; the school
teams work with the medical home and family to make immediate
temporary adjustments to ensure a successful re-entry.
 Creativity and flexibility by the school, based on symptom triggers,
are key to an early and successful recovery and re-entry process.
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Prolonged Symptoms
% Recovered
Recovery From Concussion
100
90
80
70
60
50
40
30
20
10
0
Series1
1
2
3
4
5
Weeks Post Concussion
Collins M, Lovell MR, Iverson GL, et al. Examining concussion rates and return to play in high school football players
wearing helmet technology: a three-year prospective cohort study. Neurosurgery. 2006;58(2):275–286
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Response to Intervention (RtI) or Multi-tier System of Support
RtI: Instruction and Targeted Support for All Levels of Need
Three Tiered Model of School Supports: Example of an Infrastructure Resource Inventory
Academic Systems
Tier III: Comprehensive and
Intensive Interventions – Few Students
(Students who need individualized
interventions)
Tier II: Strategic Interventions –
Some Students (Students who
need more support in addition
to the core curriculum)
Tier I: Core Curriculum –
All Students
Behavioral Systems
Tier III: Intensive Interventions – Few Students
(Students who need individualized
interventions)
Tier II: Targeted Group Interventions –
Some Students (Students who
need more support in addition
to the core curriculum)
Tier I: Universal Inventions –
All Students, all settings
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RtI/or Multi-tier System of Support as Applied to Concussion
RtI: Instruction and Targeted Support for All Levels of Need
Three Tiered Model of School Supports: Example of an Infrastructure Resource Inventory
Tier III: Special Education/IDEA
permanent brain damage = Academic
Modification of curriculum, specialized
instruction or placement
Tier II: Longer-term plan due to prolonged
effects of concussion. May be a 504 Plan =
Academic Accommodations. Still
responsible for curriculum but will provide
supports to environment, more targeted
interventions for a longer period of time
Tier I: Typical recovery from
concussion = Academic Adjustments
Universal interventions, applied in
general education, fast, fluid, flexible, put
in place immediately and lifted regularly
as symptoms improve daily
Tier III: Intensive Interventions – Few Students
(Students who need individualized
interventions)
Tier II: Targeted Group Interventions –
Some Students (Students who
need more support in addition
to the core curriculum)
Tier I: Universal Inventions –
All Students, all settings
Academic Adjustments vs. Accommodations vs. Modifications
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Interventions:
Provided in:
Affects:
Adjustments – Informal, flexible dayto-day interventions. Can be applied
immediately and lifted easily when
no longer needed.
General Education classroom.
80% to 90% of students with a
concussion for the typical 3 week
recovery.
Student still required to progress
through General Education
curriculum.
Apply for days to weeks.
Accommodations – More formal
process for longer interventions;
often called a 504 Plan. Requires a
meeting to enter and exit.
General Education classroom;
occasional extra support/targeted
interventions outside of General
Education.
5% to 15% of students with
prolonged symptoms from a
concussion.
Student still required to progress
through General Education
curriculum with accommodations to
the environment (i.e., extra time,
large print, rest).
Apply for weeks to months.
Modifications – Very formal process
to document a chronic and
permanent disability of brain injury;
referred to as Special Education or
Individuals with Disabilities
Education Act (IDEA).
Primary services provided in Special
Education classroom; student in
General Education classroom as
much as possible.
1% to 5% of students with
permanent brain damage; brain
damage sustained as a concussion.
Disability makes it so that student
cannot benefit from General
Education alone.
Allows for modification of the
General Education curriculum. Often
requires specialized instruction and
specialized placement.
Apply for months to years.
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Maximize Recovery with Academic Adjustments 80% to 90%
Tips:
Do not be too prescriptive on these initial adjustments.
Allow teachers to apply them as generously as they please
and allow them to adjust depending upon student’s:

Type of symptoms

Type of content material

Type of teaching style

Areas of strengths and weaknesses

Time of day of class
80% to 90%
Allow teachers to apply and lift interventions as they see fit. Symptoms should start
resolving from week 1 to week 2 to week 3. Academic adjustments should be lifted
over the 3 weeks and the student with the typical concussion should be almost back
to 100% pre-concussion learning level by 3 weeks.
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Special Education/IDEA/IEP 1% to 5%
Tips:
 Permanent brain damage secondary to a concussion.
 Proven over a significant amount of time that skills will
not be returning.
 MD can be helpful in documenting the brain injury but a medical
diagnosis does not automatically = an individualized education plan
(IEP).
 School gets to determine if, due to the disability, student can no
longer “benefit from General Education alone.” School is capable of
doing the assessment internally.
 If found to be appropriate for a Special Education/IDEA/IEP, student
now will need specialized instruction, specialized placement, and/or
modified curriculum.
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The Tricky “In-Between” 5% to 15%
Tips:
 Prolonged symptoms but still hoping to get close to,
if not, full recovery.
 Getting resolution with time but need more time and more
intervention.
 MD can be helpful in documenting the protracted recovery of
concussion but a diagnosis does not automatically = a 504 Plan.
 School gets to determine if the “physical impairment substantially
limits one or more major life activities” (in this case: learning).
School is capable of doing the assessment internally.
 If found to be appropriate for a 504 Plan, student will still be
responsible for the General Education curriculum but can receive
accommodations to the environment to support learning.
 A 504 Plan “levels” the playing field.
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When 504 Plans/Health Plans Can Be Very Helpful…
When you are 4+ weeks into recovery, progress is promising, but slow, and
you know recovery will take: more time and/or more treatment (i.e.,
vestibular and/or physical therapy).
Concussed student has been placed on medication for prolonged symptoms
and you know you cannot discontinue prescription for a number of months. A
504 Plan in this case will allow schools to provide specific accommodations
longer while awaiting maximum effectiveness of the prescription.
Both of the above uses of a 504 Plan help to “buy” more time for recovery and
decrease the stress of the daily questions, “Are you better today? Can you take this
test today?” It protects the student and the school.
TIP: A 504 Plan should be specific to the problem area MD is treating (i.e.,
“headaches secondary to concussion,” “mental fatigue secondary to
concussion”) and interventions should be picked thoughtfully and
prescriptively.
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Symptom Wheel
PHYSICAL
Adjustments
headache/nausea
• “strategic rest”
dizziness
scheduled breaks
balance problems
• Sunglasses
blurred vision/
• Quiet room
photophobia
COGNITIVE
environment
noise sensitivity
• More frequent breaks
neck pain
in classroom/clinic
• Remove from
ENERGY/
physical education,
EMOTIONAL
SLEEP
recess, and dance
classes without
504 Plan for “headaches secondary to a concussion:”
penalty
• Interventions:
̶
̶
allowed to wear sunglasses at school
visit nurse for pain medications and rest when
experiencing headache
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Symptom Wheel
COGNITIVE
PHYSICAL
concentration
remembering
mentally foggy
slowed processing
504 Plan for “slowed processing speed secondary to a
concussion:”
EMOTIONAL ENERGY/SLEEP
• Interventions:
̶ extra time on tests and assignments
̶ reduce number of math problems (but not
social study problems) by 50% and/or until
mastery demonstrated
̶ allow for teacher/buddy notes
Adjustments
• Workload reduction in
classroom and
homework
• Adjust “due” dates
• Allow student to “audit”
class work
• Exempt/postpone large
tests/projects
• Alternative testing
• Allow for “buddy notes”
• Allow for technology
• Do not penalize for class
work/homework not
completed during
37
recovery
McAvoy, 2011
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When 504 Plans are Not Helpful…
When you are 4 to 6+ weeks into recovery and you know you are almost ready to
turn the corner on the concussion—if the school is willing, stay the course and do
not take the time to call together a meeting for a 504 Plan. Let the student clear.
Excessive absences or truancy—a 504 Plan is not to be used to allow concussed
students to be out of school. In fact, developing a 504 Plan requires school and
MD to be even more accountable and thoughtful about educating a student while
MD is actively intervening on the medical reasons for protracted recovery. If a
student is excessively truant, consider underlying co-existing reasons (i.e., school
avoidance, anxiety).
NOTE: Home tutoring should be used sparingly, only short term, and only until the
MD can figure out why these symptoms are so severe, can find the right
treatment, and can get the student back to school. It often cannot be initiated
until student has been out of school already for 3+ weeks and it challenges Least
Restrictive Environment placement in school, so it should be used only in the
most extreme and complicated cases.
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Return to Learning Before Returning to Play (RTP)
A student with permanent brain damage, secondary to a concussion,
technically never returns 100% to pre-concussion state, technically never can
get to Step 1 of graduated RTP, and therefore cannot RTP.
Depending upon the burden of the prolonged symptoms
and the effectiveness of the treatments and/or
medications and the possible need for a 504 Plan,
getting to Step 1 of RTP steps is case by case and
therefore, clearance is case by case. However,
technically a student on a 504 Plan is not 100%
symptom-free, so technically a student cannot
start the RTP steps if a 504 Plan is still needed.
A student who returns to learning within the typical
amount of time with no complications will be at Step 1 of the graduated RTP
steps in a reasonable amount of time and RTP seems justifiable.
TM
Conclusions
1. Concussed students will need
academic adjustments in school.
2. Given that most concussions
resolve in 3 weeks, General
Education interventions are
recommended without formal
plans such as a 504 Plan or IEP.
3. Students with symptoms lasting 3
to 4 weeks may benefit from a
more detailed assessment and
consideration of a 504 Plan, but
likely not an IEP.
4. A team approach consisting of a
medical team, school teams, and
family team is ideal.
5. Students should be performing at
their academic “baseline” before
being returned to sports.
6. Education of all individuals involved
with students who sustain a
concussion is necessary to provide
adequate academic adjustments,
accommodations, and
modifications.
7. Additional research is necessary to
strengthen evidence-based
recommendations for appropriate
academic adjustments for students
following a concussion.
TM
Looking for additional school health
or sports medicine guidance?
Council on School Health
The Council on School Health (COSH) defines school health as an integration
of wellness, safety, growth, learning, and development in the lives of schoolaged children and adolescents within the context of their school, and with the
coordinated alliance of the family and the medical home. For more
information visit www2.aap.org/sections/schoolhealth/
Council on Sports Medicine and Fitness
The Council on Sports Medicine and Fitness (COSMF) supports and
encourages optimal and safe physical activity in the pediatric population and
ensures that pediatric providers are prepared to provide the highest level of
sports medicine guidance and care for their patients. For more information
visit www.aap.org/COSMF
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