Following sport-related concussion, the priorities for student athletes are return to school and extracurricular activities. Consensus-based practice recommendations emphasize rest and gradual resumption of activities. Specific evidence-based recommendations are not available. This article provides recommendations, strategies, and a general approach to the recovery process. Most youth recover clinically and return to their normal activities within the first month following injury. It is best to avoid prolonged time off from school and restrictions on social and recreational activities because these might result in adverse consequences, such as life stress, depression, and falling behind in school.
Key points
- •
There are individual differences in how and when to return to school following sport-related concussion. Some return immediately and fully, and others benefit from a gradual approach. A supportive and progressive approach to the return to school is recommended.
- •
A key principle for youth with symptoms persisting beyond the first week is to learn how to engage in optimal activity levels (ie, maximizing activity and productivity while minimizing exacerbation of symptoms).
- •
Individualized, targeted accommodations can be helpful to facilitate a faster, less stressful, and successful return to school.
Introduction
Following sport-related concussion, the first priority for children and adolescents is the safe, swift, effective, and sustained return to school. The second priority is a full and successful return to extracurricular activities—including sports. Consensus-based practice recommendations emphasize that student athletes should rest following injury, gradually resume activities, and that children should be treated more conservatively than college and professional athletes. The tripartite recommendation for rest, gradual activation, and conservatism presents challenges for the clinician. Specific evidence-based recommendations for how to implement this general management strategy are not available. Nevertheless, practical and logical recommendations can be provided to reintegrate the student back into the school environment, and to provide guidance regarding activities that might provoke or exacerbate symptoms during the day. This process requires a constructive working relationship between the school and the community health care provider who is managing the medical recovery; both bring essential skills to the process. According to meta-analyses of the available literature, sport-related concussions have a large adverse effect on cognition in the first 24 hours with resolution of these deficits occurring within about 1 week, according to group studies. Clinicians working with injured athletes, especially high school students, know that many take much longer to recover. In fact, in a prospective study of high school football players, only 42% to 47% were deemed functionally recovered by 1 week (Figure 1, Collins, et al., “Sport-related concussion” in Brain injury medicine: principles and practice, 2012, page 503). It was not until 4 weeks that 84% to 94% were considered recovered. Clearly, sport-related concussion causes symptoms (eg, headaches and fatigue) and cognitive difficulties that can make it difficult for a student to be effective in school.
To define the types of school-related problems experienced by students, a clinic sample of elementary, middle, and high school students (n = 216) was asked to describe postinjury problems that they were having in school. They reported difficulty paying attention (58%), understanding new material (44%), and slowed performance when completing homework (49%). In addition, they reported headaches interfering with learning (66%) and fatigue in class (54%). High school students reported more of these in-school problems than students in younger grade levels. The number of school problems was positively correlated with postconcussion symptoms, indicating that the more symptomatic students tended to struggle the most in school.
This article addresses a gap in the published literature. The foundation for this article is an article by Gioia and materials from the Center for Disease Control and Prevention concussion education program. The reader can also obtain educational materials from 3 other sources for school management and supports: the Colorado Reduce, Educate, Adjust/Accommodate, Pace (REAP) program, the Oregon Brain 101 program, and Pennsylvania’s BrainSTEPS program. At a systems level, Gioia and colleagues have articulated the essential components of an educational infrastructure to support the return to school of students following concussion. Ideally, state and local policies for return to school are in place to promote implementation of a consistent process. The 5 components to build this support infrastructure include: (1) defining and training an interdisciplinary school concussion management team, (2) professional development of the school and medical communities with respect to concussion management in the school; (3) identification, assessment, and progress monitoring protocols; (4) availability of a flexible set of intervention strategies to accommodate the student’s recovery needs; and (5) systematized protocols for active communication among medical, school, and family team members.
School personnel and health care providers play important and cooperative roles in the provision of supports for the returning student with a concussion. School personnel provide their expertise in developing the academic accommodations and adjustments; however, they need guidance from the health care provider on the specific targets toward which they should direct the school supports. The medical evaluation and the resulting student symptom profile is the first step to constructing the plan of accommodations and adjustments. An assessment using a standardized questionnaire can define the key symptom targets that the school can address in their intervention plan. In addition, the health care provider can work with the student and parent, using basic education and reassurance about a positive recovery, providing general guidance regarding activity allowances and restrictions, and discussing the types of targeted strategies available to manage and alleviate specific symptoms.
Introduction
Following sport-related concussion, the first priority for children and adolescents is the safe, swift, effective, and sustained return to school. The second priority is a full and successful return to extracurricular activities—including sports. Consensus-based practice recommendations emphasize that student athletes should rest following injury, gradually resume activities, and that children should be treated more conservatively than college and professional athletes. The tripartite recommendation for rest, gradual activation, and conservatism presents challenges for the clinician. Specific evidence-based recommendations for how to implement this general management strategy are not available. Nevertheless, practical and logical recommendations can be provided to reintegrate the student back into the school environment, and to provide guidance regarding activities that might provoke or exacerbate symptoms during the day. This process requires a constructive working relationship between the school and the community health care provider who is managing the medical recovery; both bring essential skills to the process. According to meta-analyses of the available literature, sport-related concussions have a large adverse effect on cognition in the first 24 hours with resolution of these deficits occurring within about 1 week, according to group studies. Clinicians working with injured athletes, especially high school students, know that many take much longer to recover. In fact, in a prospective study of high school football players, only 42% to 47% were deemed functionally recovered by 1 week (Figure 1, Collins, et al., “Sport-related concussion” in Brain injury medicine: principles and practice, 2012, page 503). It was not until 4 weeks that 84% to 94% were considered recovered. Clearly, sport-related concussion causes symptoms (eg, headaches and fatigue) and cognitive difficulties that can make it difficult for a student to be effective in school.
To define the types of school-related problems experienced by students, a clinic sample of elementary, middle, and high school students (n = 216) was asked to describe postinjury problems that they were having in school. They reported difficulty paying attention (58%), understanding new material (44%), and slowed performance when completing homework (49%). In addition, they reported headaches interfering with learning (66%) and fatigue in class (54%). High school students reported more of these in-school problems than students in younger grade levels. The number of school problems was positively correlated with postconcussion symptoms, indicating that the more symptomatic students tended to struggle the most in school.
This article addresses a gap in the published literature. The foundation for this article is an article by Gioia and materials from the Center for Disease Control and Prevention concussion education program. The reader can also obtain educational materials from 3 other sources for school management and supports: the Colorado Reduce, Educate, Adjust/Accommodate, Pace (REAP) program, the Oregon Brain 101 program, and Pennsylvania’s BrainSTEPS program. At a systems level, Gioia and colleagues have articulated the essential components of an educational infrastructure to support the return to school of students following concussion. Ideally, state and local policies for return to school are in place to promote implementation of a consistent process. The 5 components to build this support infrastructure include: (1) defining and training an interdisciplinary school concussion management team, (2) professional development of the school and medical communities with respect to concussion management in the school; (3) identification, assessment, and progress monitoring protocols; (4) availability of a flexible set of intervention strategies to accommodate the student’s recovery needs; and (5) systematized protocols for active communication among medical, school, and family team members.
School personnel and health care providers play important and cooperative roles in the provision of supports for the returning student with a concussion. School personnel provide their expertise in developing the academic accommodations and adjustments; however, they need guidance from the health care provider on the specific targets toward which they should direct the school supports. The medical evaluation and the resulting student symptom profile is the first step to constructing the plan of accommodations and adjustments. An assessment using a standardized questionnaire can define the key symptom targets that the school can address in their intervention plan. In addition, the health care provider can work with the student and parent, using basic education and reassurance about a positive recovery, providing general guidance regarding activity allowances and restrictions, and discussing the types of targeted strategies available to manage and alleviate specific symptoms.
Recommendations for return to school following injury
There are considerable individual differences in the rate at which students are ready to return to school following injury, with some returning immediately and fully and others returning gradually with accommodations. The authors typically encourage youth to return to school during the first week following injury and, if symptomatic, we encourage accommodations. Those who have not returned in 2 weeks should be evaluated carefully to determine why because prolonged absence from school can have significant negative effects. Several different accommodations might be reasonable and necessary during the initial days, and sometimes weeks, following injury. Examples of these accommodations are provided in Table 1 . As previously noted, the health care provider’s initial evaluation of symptoms is a good place to start in developing the accommodations plan. Table 1 provides examples of how symptoms cause challenges in school, with various accommodations that can be used to reduce symptoms and improve overall functioning in school. Some students might benefit from a small number of accommodations for only a few days, whereas students with symptoms that persist for several weeks might benefit from more accommodations and a careful management plan to facilitate their academic success. Regular monitoring of symptoms with adjustments to the accommodations as the student progresses through recovery can be helpful.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
