REAP The Benefits of Good Concussion Management. Center for Concussion The REAP Project Reduce Educate Accommodate Pace

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1 How every family, school and medical professional can creae a Communiy-Based Concussion Managemen Program SM REAP The Benefis of Good Concussion Managemen Cener for Concussion SM The REAP Projec Reduce Educae Accommodae Pace Auhored by Karen McAvoy, PsyD

2 Abou he Brain Injury Associaion of New York Sae A saewide, non-profi membership organizaion, he Brain Injury Associaion of New York Sae, (BIANYS) provides help and hope for individuals wih brain injury and heir families. The Associaion is he premier suppor and advocacy organizaion in New York Sae for hose hrus ino he ofen confusing and overwhelming world of brain injury, offering informaion, answering quesions, sharing experiences, providing comfor and caring, as well as promoing prevenion. Through is comprehensive Family Advocacy, Counseling, and Training Services Program (FACTS), online LEARNe resource, as well as raining, public educaion, advocacy, chapers and suppor groups, BIANYS assures no one is forced o face he rauma of brain injury alone. BIANYS is he charered sae affiliae of he Brain Injury Associaion of America. Think Smar! Think Smar! Is a hospial-based program for concussion managemen wih a eam approach. S. Charles parners wih school disrics in Suffolk and Nassau counies o provide concussion educaion and awareness o suden ahlees, parens, coaches, rainers, ahleic direcors and school nurses. Clinicians a S. Charles also provide pre-season baseline esing for ahlees paricipaing in conac spors. The 20-minue neurocogniive, compuerized es is aken again by suden ahlees if a concussion occurs. Tes resuls are compared for diagnosic purposes. S. Charles has provide baseline esing o more han 14,000 suden ahlees a 33 Long Island school disrics, wih more anicipaed. The oupaien Think Smar! Concussion Managemen Cener a S. Charles, in collaboraion wih Advanced Rehabiliaion Medicine and Orhopedic Associaes of Long Island, provides a coninuum of care for concussion ha includes injury assessmen, recovery and evenually a safe reurn o play. When an injury occurs, services begin wih he Emergency Deparmen where saff is specially rained o riage and care for ahlees following an acue concussion. In he oupaien Concussion Managemen Cener, he suden ahlee is seen by a muli-disciplinary eam of concussion managemen rained physicians, neuropsychologiss and physical herapiss where an individualized reamen plan is developmen as well as a safe progressive reurn-o-play. COPYRIGHT 2013 KAREN MCAVOY, PSYD Las revised June 2012 Suppor is provided in par by he New York Sae Deparmen of Healh (NYSDOH) by projec H21MC06742 from he Deparmen of Healh and Human Services (DHHS), Healh Resources and Services Adminisraion, Maernal and Child Healh Bureau. Auhored by: Karen McAvoy, PsyD Karen McAvoy, Psy. D, and HCA-HealhONE LLC wan o acknowledge and hank he Colorado Traumaic Brain Injury Trus Fund for providing he original funding for he developmen of he REAP Projec. Brain Injury Associaion of New York Sae 10 Colvin Avenue Albany, New York / S. Charles Hospial 200 Belle Terre Road Por Jefferson, New York Original funding from:

3 SM The REAP Projec which sands for Reduce Educae Accommodae Pace is a communiy-based model for Concussion Managemen ha was developed in Colorado. The early origins of REAP sem from he dedicaion of one ypical high school and is surrounding communiy. Afer he devasaing loss of a suden o Second Impac Syndrome, he Adminisraors, Teachers, Cerified Ahleic Trainer, School Nurse, School Psychologis and Counselors all banded ogeher o creae a wider safey ne for all sudens in ha school. The ne became sronger when parens and communiy medical professionals also worked ogeher o coordinae care and recovery from concussion. The lessons learned from his ragic even are ha a Muli-Disciplinary Team approach is he foundaion of good Concussion Managemen. The Muli-Disciplinary Teams: Family Team School Physical Team School Academic Team Medical Team These eams work closely o wach and care for he suden/ahlee during his or her enire recovery from concussion. The wriing of REAP was funded by an Educaion Gran from he Colorado Traumaic Brain Injury Trus Fund in From 2009 o 2010, REAP was piloed a eigh HealhONE Emergency Deparmens and four school disrics. In one year ( ), he REAP projec received more han 150 referrals of sudens/ahlees evaluaed in Emergency Deparmens (ED) for concussion. Afer leaving he EDs, families, schools and communiy medical professionals were quickly conaced by he REAP Projec and educaion and communiy collaboraion commenced immediaely. Counless more REAP referrals sponaneously developed in communiies via word of mouh beween parens, physicians, schools and disrics. The shor-erm and he long-erm benefis from REAP have been overwhelmingly posiive. REAP is coninuing o expand across Colorado as a model program for Communiy- Based Concussion Managemen. I is a model ha empowers schools, school disrics, families, sudens and medical professionals o come ogeher o coordinae, collaborae and o help young people achieve he safes recovery from concussion. Download a digial version of his publicaion a and Table of Conens Inro and message o parens...1 How o use his manual...2 Reduce...3 Educae...4 R.E.A.P. imeframe...7 Accommodae...8 Pace...9 Special Consideraions...11 Resources...12 Appendix...13 Teacher Templae Sympom Checklis

4 > > > > > > > > > Concussion recovery is exremely variable, which is why we rea each paien wih a personalized reamen and recovery plan. We know ha children and adolescens ake longer o fully recover from hese injuries as he brain is sill developing, and ha reurning o play oo soon may no allow he brain o fully heal. I is imporan o ensure complee recovery of our suden ahlees prior o reurn o spors o preven poenially severe consequences, such as Second Impac Syndrome, as well as avoid long lasing cogniive and physical effecs. - Jennifer Gray, MD TRUE or FALSE? TRUE or FALSE? A concussion is jus a bump on he head. A paren should awaken a child who falls asleep afer a head injury. False! Acually, a concussion is a raumaic brain injury (TBI). The sympoms following a concussion can range from mild o severe and usually involve: confusion, disorienaion, memory loss, slowed reacion imes and exreme emoional reacions. The severiy of he sympoms canno be prediced a he ime of he injury. False! Curren medical advice is ha i is no dangerous o allow a child o sleep afer a head injury, once hey have been medically evaluaed. The bes reamen for a concussion is sleep and res. TRUE or FALSE? A concussion is usually diagnosed by neuroimaging ess (ie. CT scan or MRI). False! Concussions canno be deeced by neuroimaging ess; a concussion is a funcional no srucural injury. Concussions are ypically diagnosed by careful examinaion of he signs/sympoms of concussion a he ime of injury. The cause of sympoms during a concussion are hough o be due o an ENERGY CRISIS in he brain cells. A he ime of a concussion, he brain cells (neurons) sop working normally. The fuel (sugar) ha is needed o generae aciviy for playing and for hinking- is simply no being delivered efficienly o he cells. As a resul, a sympom will flare. I is he brain s way of elling he body ha i is no working properly. While a CT scan or an MRI is ofen used o rule ou more serious bleeding in he brain, i is no a diagnosic es for concussion. A negaive scan does no mean ha a concussion did no occur.

5 Did You Know... >> More han 80% of concussions resolve very successfully if managed well wihin he firs hree weeks pos-injury. 1 REAP sees he firs hree weeks pos- injury as a window of opporuniy. Research shows ha he average recovery ime for a child/adolescen is abou hree weeks, slighly longer han he average recovery ime for an adul. 2 >> The REAP projec works on he premise ha concussion is bes managed by a Muli- Disciplinary Team ha includes: he Suden/Ahlee, he Family, various members of he School Team and he Medical Team. The unique perspecive from each of hese various eams is essenial! >> The firs day of he concussion is considered Day 1. The firs day of recovery also sars on Day 1. The REAP Projec can help he Family, School and Medical Teams mobilize immediaely o maximize recovery during he enire hree week window of opporuniy. TRUE or FALSE? Loss of consciousness (LOC) is necessary for a concussion o be diagnosed. False! According o he American Academy of Neurology (AAN), a concussion is any raumaically induced aleraion in menal saus ha may or may no involve a loss of consciousness. CDC repors ha an esimaed 1.6 o 3.8 million spors- and recreaion-relaed concussions occur in he Unied Saes each year. 3 Niney percen of concussions do no involve a loss of consciousness. While many sudens receive a concussion from spors-relaed aciviies, numerous oher concussions occur from non-spors relaed aciviies from falls, from moor vehicle, bicycle and playground accidens. Message o Parens To maximize your child s recovery from concussion, double up on he R s. REDUCE and REST! Insis ha your child res, especially for he firs few days pos-concussion and hroughou he hree-week recovery period. Some sympoms of concussion can be so severe on he firs day or wo ha your child may need o say home from school. When your child is a school, reques ha he/she be allowed o si ou of spors, recess and physical educaion classes immediaely afer he concussion. Work wih your Muli-Disciplinary Concussion Managemen Team o deermine when your child is ready o reurn o physical aciviy, recess and/or PE classes (see PACE). Don le your child convince you he/she will res laer (afer he prom, afer finals, ec.). Res mus happen immediaely! The school eam will help your child reduce heir academic load (see AC- COMMODATE). However, i is your job o help o reduce sensory load a home. Advise your child/een o: avoid loud group funcions (games, dances) limi video games and ex messaging limi reading and homework A concussion will almos universally slow reacion ime; herefore, driving should no be allowed pending medical clearance. Pleny of sleep and quie, resful aciviies afer he concussion maximizes your child s chances for a grea recovery! page 1

6 page 2 Communiy-Based Muli-Disciplinary Concussion Managemen Team How o use his Manual Because i is imporan for each member of he Muli-Disciplinary Concussion Managemen Team o know and undersand heir par and he par of oher members, his manual was wrien for he enire eam. However, as informaion is especially perinen o a cerain group, i is noed by a color. >> Pay close aenion o he secions in ORANGE ST/A FT Family Team Suden, Parens; may include Friends, Grandparens, Primary Careakers and ohers For more specific informaion, download paren fac shees from he various Heads Up Toolkis on he CDC websie: >> Pay close aenion o he secions in LIGHT BLUE ST/P School Physical Team Coaches, Cerified Ahleic Trainers (ATC), Physical Educaion Teachers, Playground Supervisors, School Nurses and ohers For more specific informaion, download he free Heads Up: Concussion in High School Spors or Concussion in Youh Spors from he CDC websie: >> Pay close aenion o he secions in DARKER BLUE ST/A School Academic Team Teachers, Counselors, School Psychologiss, School Social Workers, Adminisraors, School Neuropsychologiss and ohers For more specific informaion, download he free Heads Up o Schools: Know Your Concussion ABCs from he CDC websie: MT >> Pay close aenion o he secions in GREEN Medical Team Emergency Deparmen, Primary Care Providers, Nurses, Concussion Specialiss, Neurologiss, Clinical Neuro-psychologiss and ohers For more specific informaion, download he free Heads Up: Brain Injury in your Pracice from he CDC websie: REDUCE EDUCATE ACCOMMODATE PACE SPECIAL CONSIDERATIONS RESOURCES APPENDIX

7 Allie Kem 7 h Grade On Sepember 25h, 2011, I was hi in he head wih a ball during a lacrosse ournamen. A player from he oher eam was shooing on goal bu he ball bounced off he goal pos, hiing me square in he forehead. The nex day, he docor old me I had a concussion. Inegraing back ino a normal school schedule was a big challenge for me. Alhough I had he help of my parens and some help from school, I sill fel overwhelmed and very behind in my work. I have o admi, i was scary. Trying o keep up wih my grades was hard, bu hroughou he year I have managed o mainain my spo on high honor roll. Some advice ha I would give o sudens wih his same ype of injury would be o never feel alone and o never be afraid o ask for help. I would also advise sudens o ry and say conneced wih heir friends and o make sure hey undersand wha you are going hrough. Unforunaely, here are many challenges ha come along wih a head injury. I believe ha wih he large amoun of sudens who ge head injuries, all schools should be prepared for when a suden ges a concussion. Afer your child/suden has been evaluaed and deermined o have a concussion, There is One Immediae and Essenial Focus >>Reduce he poenial of furher injury or sress o he brain! Wih concussion, i is imporan o reduce boh physical AND cogniive demands! Mos of us know ha when an ahlee is injured, sress on ha injured area needs o be immediaely reduced. If an ahlee sprains an ankle while running a marahon, he immediae acion is o remove he runner from he race. Wih proper managemen of he injury and gradual rehabiliaion, he ahlee may be allowed o run again in a laer race. Ahlees know ha following injury, immediae removal from aciviy and gradual reurn o aciviy is necessary o avoid serious, long-erm physical effecs or he poenial for re-injury. Following a concussion, he suden/ahlee should be removed from spors, recess, physical educaion classes, ec. unil furher noice (see PACE). In he marahon of life, a concussion is much like he sprained ankle i is an injury o he brain. Since he brain is he organ responsible for managing all moving (physical) and hinking (cogniive) funcions of he body, boh physical and cogniive demands on he brain mus be reduced during recovery from concussion. Reducing jus he physical demands alone (and no he cogniive demands) may delay or hamper recovery. Since school is he place where hinking demands are a heir highes, REAP places grea emphasis on helping he School Team-Academic (ST/A) undersand heir par in concussion managemen. In REAP, he ACCOM- MODATE page will help schools provide sraegies for cogniive reducion in school. In rare cases, an unresolved concussion may se he sage for permanen brain damage and/or deah. This phenomenon, known as Second Impac Syndrome (SIS), heoreically can occur when a second blow o he head is susained before he firs concussion has healed. 4 The concern for SIS in he developing adolescen brain has led o he pracice ha concussion sympoms should be 100% resolved before furher significan physical or cogniive sress is encounered. REDUCE page 3

8 page 4 EDUCATE Once he injury happens, he reamen of choice is o EDUCATE and COLLABORATE Did you know ha a docor canno predic he course of recovery a he ime of he injury? The course of recovery depends 100% on he on-going (someimes daily) monioring, managemen and resoluion of sympoms! >> STEP 1: Educae...Know he Sympoms Knowing if he suden/ahlee is recovering from he sympoms of concussion and how he suden/ahlee is recovering from his/her sympoms is sill he bes measure of recovery. Therefore, i is essenial ha everyone undersand, recognize and be mindful of ALL sympoms relaed o concussion. Every sympom is imporan. The common sympoms of concussion cluser in general caegories: PHYSICAL How a Person Feels Physically Headache/Pressure Blurred vision Dizziness Poor balance Ringing in ears Seeing sars Vacan sare/glassy eyed Nausea Vomiing Numbness/Tingling Sensiiviy o ligh Sensiiviy o noise Disorienaion Neck Pain COGNITIVE How a Person Thinks Feel in a fog Feel slowed down Difficuly remembering Difficuly concenraing/easily disraced Slowed speech Easily confused Medical Box I is no appropriae for a child or adolescen ahlee wih concussion o Reurn-o-Play (RTP) on he same day as he injury, regardless of he ahleic performance. 5 Consensus Saemen on Concussion in Spor: he 3rd Inernaional Conference on Concussion in Spor, Zurich 2008 EMOTIONAL How a Person Feels Emoionally Inappropriae emoions Irriabiliy Personaliy change Sadness Nervousness/Anxiey Lack of moivaion Feeling more emoional MAINTENANCE How a Person Experiences Their Energy Level and/or Sleep Paerns Faigue Excess sleep Trouble falling asleep Drowsiness Sleeping less han usual Thorough sympom monioring is he key o good managemen. Therefore, REAP srongly suggess ha all Muli-Disciplinary Concussion Team members, especially he suden/ahlee, learn o rae sympoms on a severiy level of 0 o 6. Assigning numbers o sympom inensiy provides an objecive measure and a common language for all eam members o undersand (see he Sympom Checklis in he APPENDIX). IMPORTANT! All sympoms of concussion are imporan; however, monioring of physical sympoms, wihin he firs 48 o 72 hours, is criical! If physical sympoms worsen, especially headache, confusion, disorienaion, vomiing, difficuly awakening, i is ofen a sign ha a more serious medical condiion is developing in he brain. SEEK IMMEDIATE MEDICAL ATTENTION!

9 >> STEP 2: Collaborae...Managing Your Muli-Disciplinary Concussion Managemen Team Mos sudens/ahlees repor ha sympoms of concussion are mos inense and mos frequen Days 1 hrough 4, coninue hroughou Week 1 and begin o wane during Weeks 2 and 3. REAP has developed a suggesed imeframe o check and monior sympoms over a hree-week period. REAP has also assigned recommended responsibiliies o cerain eams o manage specific sympoms. As every concussion is differen and unique, each Concussion Managemen Team mus remain fluid and flexible. REAP is based upon he premise ha here are a few elemens ha are essenial o any good concussion managemen program. Those essenial facors are: A Muli-Disciplinary Team Team members who provide muliple perspecives of he suden/ahlee AND Team members who provide muliple sources of daa As long as a school/communiy can accommodae for he essenial elemens lised above, he principles of REAP (aka good concussion managemen) can be applied successfully across any communiy or school disric. On a case-by-case basis, each Muli-Disciplinary Team should uilize he guidelines recommended in REAP o deermine: Message o Educaors Second impac syndrome causes a meabolic change in he brain. I doesn cause a srucural problem o he brain, which is why a sandard MRI or CAT scan is negaive. However if an ahlee akes anoher big hi, hose chemical processes change exponenially and cause problems in he cells wih swelling and he poenial for immediae, severe and long-lasing issues. - Dr Jennifer Gray The REAP Manual canno prescribe who will be on each eam differen schools have differen resources and no all schools have all resources. However, mos ypically, he ATC, School Nurse (or Healh Aide) ofen acs as he ST/P. In some creaive school disrics, a well-educaed Coach or Office Manager has aced as he ST/P. Similarly, ypically he School Psychologis/Social Worker or Counselor ofen acs as he ST/A. However, on occasion, a very dedicaed General Educaion Teacher has served as he ST/A. coninues on nex page Who will be on he Family Team (FT)? Who from he family will wach, monior and rack he emoional and mainenance sympoms of he concussion and how will he Family Team communicae wih he School and Medical Who will be on he School Team Physical (ST/P)? Who a he school will wach, monior and rack he physical sympoms of he concussion? Who is he ST/P Poin Person? Who will be on he School Team Academic (ST/A)? Who a he school will wach, monior and rack he academic and emoional effecs of he concussion? Who is he ST/A Poin Person? Who will be on he Medical Team (MT)? How will he MT ge informaion from all of he oher eams and who will be responsible for communicaing wih he MT? EDUCATE For each case, who will be he overall REAP Manager and coordinae he vorex of informaion beween he FT, ST/P, ST/A and MT? page 5

10 page 6 EDUCATE In order o obain a common language beween all Concussion Managemen Team members, an objecive measure of sympoms has been found o be helpful. Therefore, one imporan suggesion in REAP is ha he REAP Manager (on each paricular concussion case) ake responsibiliy for meeing wih he suden (daily or a specified inervals, see REAP TIMEFRAME) o help he suden/ahlee rae sympoms. Areas of sympom concern/improvemen are hen shared wih he oher eam members responsible for managing differen sympoms. This allows for immediae accommodaions/adjusmens o be made. In our experience, he majoriy of communicaion occurs beween eam members via phone or . Formal meeings have rarely been necessary. The REAP Projec promoes beer managemen of concussion hrough beer managemen of informaion and beer coordinaion beween eam members. REAP realizes ha every communiy and every school disric has srenghs and limiaions. If resources allow for only one Poin Person a a school, i is imporan ha ha one person be equally commied o managing all sympoms cogniive, emoional, mainenance, as well as, physical sympoms. I is possible ha in some smaller communiies, here may only be one person on a School Team who hen has o manage boh Physical and Academic responsibiliies. Tha one school Poin Person can sill parner wih someone from he Family Team and ogeher, hey can parner wih someone from he Medical Team. REAP feels ha more eyes on he concussion and more varied perspecives (even if only hree perspecives!) lead o beer decision-making. The REAP model does no depend upon more resources. Insead i depends upon he srengh of a srongly educaed and well-coordinaed eam. Medical Box The REAP Projec is happy o provide suppor and educaion o your communiy, no maer wha your unique needs may be. We are confiden ha he essenial elemens of good concussion managemen can be achieved in any communiy wih a lo of good inen and a lile creaiviy! The imporance of recognizing and reaing concussions canno be undersaed. We have learned, over he pas several years, ha appropriae recogniion and, mos imporanly, avoidance of repea injury in he acue period are essenial in avoiding prolonged or permanen injury. Boh physical and cogniive res are paramoun in he recovery from concussion. While mos people undersand he imporance of avoiding spors/physical aciviies, praciioners have clearly recognized ha resricion from academic and daily aciviies are essenial o hasen he recovery. Once a paien becomes sympom-free, a sric proocol for boh he reurn o academic and spors aciviy is performed o ensure ha here is no relapse of sympoms. These measures allow for children o reurn o heir aciviies in he safes way possible. - Hayley Queller, MD, PC I was a regular day and a regular soccer game. Our eam had jus aemped o score, bu he goalie caugh i. He puned i, and he ball was coming in a a perfec angle for me o hi i wih my head. I hi me like i did every oher ime, and hen rebounded up he field. Only for some reason, his ime didn feel like every oher ime. I didn have a headache, and I wasn dizzy. I was jus... confused. The nex day a school was a blur. I had all of he sympoms of a concussion, and my friends could ell. I remember hem saying, you should really go see he nurse, bu I didn hink I had o. Afer school, I wen o my pediarician s office. I did have a concussion. I couldn believe ha I had goen a concussion during soccer. A he ime, I didn know ha soccer was acually one of he mos common spors for concussions. I m finally back in school, and all of my work is caugh up. The headaches and dizziness are gone, and I ve never been more hankful. However, I feel ha more work should be done o preven concussions so ha no one has o go hrough wha I did, even wih all of he help I received. John Frasier

11 >> REAP suggess he following imeframe: TEAM Week 1 Week 2 Week 3 FT Family Team Help child undersand he/she mus be a hones parner in he raing of sympoms Impose res. Assess sympoms daily especially monior mainenance sympoms and emoional sympoms. Coninue o assess sympoms (a leas 3X week or more as needed), monior if sympoms are improving. Coninue o assess sympoms and increase/decrease demands accordingly. Coninue wih all assessmens (a leas 2X week or more as needed). Coninue o assess sympoms and increase/decrease demands accordingly. *Sign a Release of Informaion so ha School Team and Medical Team can communicae wih each oher as soon as possible. ST/P School Team Physical Coach/ATC/School Nurse (Assign 1 poin person o oversee/ manage physical sympoms) REAP suggess immediae removal from play/physical aciviies! Assess physical sympoms daily, use objecive raing scale. ATC: assess posural-sabiliy (see NATA reference in RESOURCES). School Nurse: monior visis o school clinic If sympoms a school are significan, conac parens and send home from school. Coninue o assess sympoms (a leas 3X week or more as needed) and increase/decrease demands accordingly. (See PACE) ATC: posural-sabiliy assessmen. Coninue wih all assessmens (a leas 2X week or more as needed) and increase/decrease demands accordingly. (See PACE) ATC: posural-sabiliy assessmen. ST/A School Team Academic Educaors, School Psychologis, Counselor, Social Worker (Assign1 poin person o oversee/ manage cogniive/emoional sympoms) Reduce all cogniive demands (reduce, do no eliminae cogniive demands). Mee wih suden periodically o creae academic accommodaion plan for cogniive/emoional reducion no laer han Day 2/3 & hen assess again by Day 7. Educae all eachers on he sympoms of concussion (see Teacher Templae in Appendix). Make immediae academic accommodaions. See ACCOMMODATE secion. Coninue o assess sympoms (a leas 3X week or more as needed) and slowly increase/decrease cogniive and academic demands accordingly. Coninue academic accommodaions as needed. Coninue wih all assessmens (a leas 2X week or more as needed) and increase/ decrease cogniive and academic demands accordingly. Coninue academic accommodaions as needed. Assess if longer erm academic accommodaions are needed (504 Plan, IEP, ec.). MT Medical Team Assess and diagnose concussion. Educae suden/ahlee and family on he ypical course of concussion and he need for res. Monior ha sympoms are improving hroughou Week 1 no worsening in he firs 48 o 72 hours. Coninue o consul wih school and home eams. Follow-up medical check including:comprehensive hisory, neurologic exam, deailed assessmen of menal saus, cogniive funcion, gai and balance. Coninue o consul wih school and home eams. I is bes pracice ha a medical professional be involved in he managemen of each and every concussion. >> Don be alarmed by he sympoms - sympoms are he hallmark of concussion. The goal is o wach for a slow and seady improvemen in ALL sympoms over ime. I is ypical for sympoms o be presen for up o hree weeks. If sympoms persis ino Week 4, see SPECIAL CONSIDERATIONS. EDUCATE page 7

12 page 8 ACCOMMODATE Wih he adven of new brain imaging echnology, we more clearly undersand wha happens o he brain following a concussion. Mos Common Thinking Cogniive Problems Pos-Concussion And suggesed accommodaions This is a complex physiologic even ha affecs how he brain works. However, since he issue is wih funcion of he brain and no he srucure, he injury canno be seen on rouine CT scans or MRIs. As a resul he rue severiy of a concussion is ofen School unrecognized Team and underreaed. EducaorsIn order o keep our suden ahlees safe i is essenial o educae coaches, rainers, suden ahlees and heir families o anicipae and recognize sympoms and seek proper medical reamen from a healh care professional experienced in evaluaing and reaing concussions. Dr. Jennifer Semel Areas of concern Faigue, specifically Menal Faigue Difficuly concenraing Feels like being in a fog Suggesed Accommodaions > Schedule sraegic res periods. Do no wai unil he suden s over-iredness resuls in an emoional meldown. > Adjus he schedule o incorporae a minue res period mid-morning and mid-afernoon. > I is bes pracice for he suden o be removed from recess/spors. Resing during recess or PE class is advised. > Do no consider quie reading as res for all sudens. > Reduce he cogniive load i is a fac ha smaller amouns of learning will need o ake place during he recovery. > Since learning during recovery is compromised, he academic eam mus decide: Wha is he mos imporan concep for he suden o learn during his recovery? > Be careful no o ax he suden cogniively by demanding ha all learning coninue a he rae prior o he concussion. The newes research shows ha neuropsychological esing has significan clinical value in concussion managemen, especially wih eenagers and especially when baseline scores are available. The addiion of neuropsychological ess is an emerging bes pracice. However, limied resources and raining are a realiy for school disrics. An exensive lis of paper and pencil neurocogniive ess known o be sensiive o TBI can be found a Wheher or no a school disric chooses o include any ype of neurocogniive esing, REAP is sill he foundaion of he Concussion Managemen program. Daa gahered from serial pos-concussion esing (by Day 2/3, by Day 7, by Day 14 and by Day 21, unil asympomaic) can only serve o provide addiional informaion. However, no es score should ever be used in isolaion. Professionals mus adhere o all ehical guidelines of es adminisraion and inerpreaion. Slowed processing speed Feels like being convered from high speed inerne o dial up inerne Difficuly wih working memory The abiliy o emporarily sore and manage informaion during complex cogniive processes such as learning and reasoning Difficuly convering new learning ino memory Emoional sympoms > Provide exra ime for ess and projecs. > Assess wheher he suden has large ess or projecs due during he 3-week recovery period and remove or adjus due daes. > Provide a peer noeaker or copies of eacher s noes during recovery. > Iniially exemp he suden from rouine work/ess. > Since memory during recovery is limied, he academic eam mus decide: Wha is he mos imporan concep(s) for he suden o know? > Work oward comprehension of a smaller amoun of maerial versus roe memorizaion. > Allow suden o audi he maerial during his ime. > Remove busy work ha is no essenial for comprehension. Making he suden accounable for all of he work missed during he recovery period (3 weeks) places undue cogniive and emoional srain on him/her and may hamper recovery. > Ease suden back ino full academic/cogniive load. Be mindful of emoional sympoms hroughou! Sudens are ofen scared, overloaded, frusraed, irriable, angry and depressed as a resul of concussion. They respond well o suppor and reassurance ha wha hey are feeling is ofen he ypical course of recovery.

13 Managemen of Concussion is Difficul Because i is a Moving Targe A medical docor, wheher in he Emergency Deparmen or a a follow-up clinic, canno predic he lengh or he course of recovery from a concussion. In fac, a docor should no longer ell a family ha a concussion will resolve in X number of days because every concussion is differen and each recovery ime period is unique o he suden/ahlee. The bes way o assess when a suden/ahlee is ready o sar he sep-wise process of Reurning-o-Play is o ask hese quesions: Reurn o Academics Afer a concussion, one of he firs decisions a paren has o make is... should my suden/ahlee go o school? If so, when? Every suden/ahlee is differen and heir reurn o school will be based upon heir level of sympoms in he days following he concussion. As a rule of humb, a suden/ahlee may reurn o school while sympoms are sill presen bu are improving. REAP would no sugges, however, ha a suden/ahlee reurn o school if sympoms are severe (ie exreme headache, severe nausea, vomiing, major dizziness, ec.) Since sympoms are usually only severe for he firs day or wo following a concussion, i is perfecly accepable for a suden/ahlee o miss a day o wo days of school (wih severe sympoms) in he very beginning of he recovery. Rarely, however, would a suden/ahlee need o miss more han a few days of school due o a concussion. When he suden/ahlee DOES reurn o school, he paren MUST inform he school abou he concussion and he school MUST consider puing academic accommodaions in place. The level of academic accommodaion should be based upon he individual needs of he suden/ahlee. Once he suden/ahlee is a school, increasing heir cogniive load should be gradual and should follow roughly he same principles as he graduaed Reurn-o-Play. For example, he suden/ahlee will likely have olerable sympoms upon heir reurn o school. As sympoms improve, he cogniive demands can be slighly increased. Do sympoms reurn or ge inolerable? If so, reduce menal aciviy and res for 24 hours. If no, cogniive demands can coninue o be increased slowly. Remember: he suden/ahlee mus be funcioning successfully (academically) a school before he/she can be considered ready o sar he graduaed Reurn-o-Play progression. >> Do daa from muliple perspecives and muliple sources sugges ha all sympoms have resolved? >> Do all sympoms say resolved even wih exerion and even when medicaions are no longer being used? >> Is he suden/ahlee funcioning back o baseline academically (and/or on measures of cogniive abiliies)? ST/A The answers o hese quesions can only be available on a daily basis o he suden/ahlee, he family and he school eam(s). Even he mos involved medical professional will likely no be able o see he suden on a daily basis; herefore, periodic sympom assessmen mus be colleced by he Family and School Team(s) and mus be shared wih he Medical Team. The key o success is communicaion and collaboraion! In he spiri of eamwork, he decision for he suden/ahlee o begin he graduaed Reurn-o-Play (RTP) proocol and reurn o 100% paricipaion in physical aciviies canno and should no be made by any one single member of he eam. For example, an ATC should no reurn a suden/ahlee o conac spors wihou family/educaor/medical professional inpu and suppor. Likewise, a communiy medical professional should no make a Reurn o Play decision wihou family and school inpu. In addiion, REAP provides a word of cauion alhough gaining in populariy a his ime, no one single assessmen ool (compuerized or paper/pencil neuropsychological esing, balance assessmen or ohers) should ever be used in isolaion in making he RTP decision. The bes pracice is clear muliple poins of daa, from muliple sources MUST be considered o make he soundes decision. In oher words, he iniiaion of he Reurno-Play decision mus be made by consensus of he Muli-Disciplinary Concussion Managemen Team, in consulaion wih a medical professional. PACE page 9

14 page 10 PACE The 2008 Zurich Consensus Saemen on Concussion in Spor Recommends A Graduaed Reurn-o-Play (RTP) STAGE ACTIVITY FUNCTIONAL EXERCISE CHILD/STUDENT EQUIVALENT OBJECTIVE OF STAGE No physical aciviy as long as here are sympoms (This sep could ake days or even weeks) Ligh aerobic aciviy Complee physical res Quie ime wih maximum res Recovery When 100% sympom free for 24 hours proceed o Sage 2. (Recommend longer sympom-free periods a each sage for younger suden/ahlees) Walking, swimming, saionary cycling minues of exercise, no resisance Soliary play or quie play alone or wih paren If sympoms reemerge wih his level of exerion, hen reurn o he previous sage. If he suden remains sympom free for 24 hours afer his level of exerion, hen proceed o he nex sage. Spor-specific exercise Skaing/running drills, minues - no weighlifing, no head conac Supervised play, low risk aciviies If sympoms re-emerge wih his level of exerion hen reurn o he previous sage. If he suden remains sympom free for 24 hours afer his level of exerion hen proceed o he nex sage. Increase hear rae (ligh o moderae workou no requiring cogniive aenion or high degree of coordinaion) Add movemen (increased aenion and coordinaion required) 4 Non-conac raining drills Progression o more complex raining drills; may sar progressive resisance raining May run/jump as oleraed If sympoms re-emerge wih his level of exerion hen reurn o he previous sage. If he suden remains sympom free for 24 hours afer his level of exerion hen proceed o he nex sage. Exercise, coordinaion (mimics ahlee s spor wihou risk of head injury) 5 6 Full-conac pracice Reurn o play Following medical clearance, paricipae in normal raining aciviies; full exerion Normal paricipaion wih parenal/ adul supervision If sympoms re-emerge wih his level of exerion hen reurn o he previous sage. If he suden remains sympom free for 24 hours afer his level of exerion hen proceed o he nex sage. Normal game play Normal playime No resricions Resore confidence and assess funcional skills by coaching saff (or family) Graduaed Pacing Concussion Day 1 REST REST Reurn o previous sep where suden/ahlee was wihou sympoms. Res 24 hours before aemping he nex higher sep again. Physical: Once sympom-free, increase physical demands via sep-wise progression Cogniive: Once sympoms are olerable, increase cogniive demands slowly Physical: Do sympoms reurn or worsen wih added physical demand? Cogniive: Do sympoms reurn or worsen wih increased cogniive or emoional demands? Reurn o previous sep where suden/ahlee was wihou sympoms. Res 24 hours before aemping he nex higher sep again. If YES If NO If NO If YES Physical: Coninue o progress hrough seps unil Reurn-o-Play (RTP) Cogniive: Coninue o slowly increase cogniive demands unil Reurn-o-Full-Learning McCrory P, Meeuwisse W, Johnson K, Dvorak J, Aubry M, Molloy M, Canu R. Consensus Saemen on Concussion in Spor: The 3rd Inernaional Conference on Concussion in Spor Held in Zurich, November J Ahl Train. 2009;44(4):

15 Special Consideraions >>When Sympoms do no Resolve as Expeced Approximaely 10% o 20% of concussions do no resolve in one o hree weeks. When, and if, sympoms (physical, cogniive, emoional or mainenance) do no resolve as expeced, i is suggesed ha he suden/ahlee work wih heir medical professional o pursue a more specialized oupaien evaluaion (medical, neuropsychological or psychosocial). As saed hroughou his manual, an uncomplicaed concussion will generally resolve wihin one o hree weeks. Excep for he mos acue phases of he concussion (usually Days 1 or 2), i is no advised for suden/ahlees o be absen from school due o he concussion. In an exremely rare case in which long-erm sympoms of he concussion resul in an exended absence from school, i would be bes for he suden/ahlee o be considered for assessmen and/or services under a 504 Plan or IDEA /Traumaic Brain Injury. 6 I is beyond he scope of his manual o speak o assessmen and programming for brain injury. Many school disrics have Brain Injury Teams, which can provide suppor. Some Deparmens of Educaion have a regional TBI Coordinaor available for saewide consulaion. Educaors can find guidelines for brain injury a Oher brain injury resources are lised in he RESOURCES secion. >>Long-Term Monioring Sudies have had difficuly esimaing he rue number of sudens/ahlees who may iniially recover well from a concussion bu suffer laer from learning, emoional or behavioral issues. Are hose problems relaed o he earlier concussion? No one can say for sure, bu educaors suspec here may be some connecion especially in he case of muliple concussions. The REAP Projec provides a model by which families, schools and medical professionals can manage he concussion in he shor-erm hree weeks. However, i has become clear ha REAP provides a more global gif. In he process of managing a concussion for hree weeks, he suden/ahlee becomes known o a muli-disciplinary eam. As he suden/ahlee progresses beyond he concussion, he family, he school and he medical professional become cognizan of he injury and can rack he suden/ahlee forward. >> If physical sympoms reurn or are exacerbaed, immediae medical aenion can be sough. >> If emoional or personaliy changes are noed by parens, hey can voice heir concern o schools or medical professionals. >> If learning or behavioral changes are noed by he school, eam members will know o quesion heir connecion o he recen resoluion of he concussion and can pursue assessmen or inervenion. In an academic seing, his abiliy o recognize problems and inervene early is consisen wih he federal mandae of Response o Inervenion (RTI). REAP provides a emplae by which concussions can be racked forward. Wih REAP, good concussion managemen does no end wih he hree-week recovery of a single Medical Box We really didn know wha o expec for John. The healing process was very difficul for him. Every day, I kep hoping he would feel a lile beer and have some relief from his errible headaches. We realized ha his concussion would ake as much ime as i needed o heal. Never in a million years would I have hough ha John would miss almos 3 monhs of school from heading a soccer ball! There were several challenges wih John s injury. The more difficul one was rying o keep him low-key on he days ha he fel beer. He missed his friends, compuer, and video games, bu jus a lile overload on his good days would se him back several more. The key o John s recovery process was he suppor he received a school. I had consan conac wih he counselor and John s eachers. Evenually, John was able o aend half days wih he opion o go o he nurse s office if needed. He was allowed o es in a separae room if he noise and/or lighs in he classroom bohered him. The abiliy o ease him back ino he classroom and lunch room was a big help in his recovery. Too much simulaion boh in and ou of he classroom would cause difficulies. Luckily, John has fully recovered from his concussion and ended up on he High Honor Roll despie missing mos of he fall semeser. I don know wha we would have done wihou he suppor and guidance we received from he Concussion Managemen program and John s school counselors, eachers, and saff, and I hope ha some of our experiences will help ohers in heir journey o recovery. Marianne Frasier concussion. In he shor run, REAP raises awareness o assure ha all sudens/ahlees fully recover, one concussion a a ime. In he long run, REAP places responsibiliy on he communiy o assure ha, wih he knowledge of pas concussions, we keep sudens/ahlees safe from he vulnerabiliy of fuure concussions. SPECIAL CONSIDERATIONS page 11

16 page 12 RESOURCES Resources Ceners for Disease Conrol (CDC) CDC-INFO REFERENCES Brain Injury Assn. of NYS Collins, MW, Lovell, MR, Iverson, GL, Ide, T, Maroon, J. Examining concussion raes and reurn o play in high school fooball players wearing newer helme echnology: A hree-year prospecive cohor sudy. Neurosurgery 2006; 58: LEARNe Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from spors-relaed concussion? A comparison of high school and collegiae ahlees. J Pediarics. 2003; 142(5); NYS Deparmen of Healh (ype TBI in search box) Langlois JA, Ruland-Brown W, Wald MM. The epidemiology and impac of raumaic brain injury: a brief overview. J Head Trauma Rehabil. 2006; 21: Canu RC. Second impac syndrome. Clin Spors Med. 1998; 17: NYS Public High School Ahleic Assn McCrory, P., Meeuwisse, W., Johnson, K., Dvorak, J., Aubry, M., Molloy, M., Canu, R. Consensus Saemen on Concussion in Spor: The 3rd Inernaional Conference on Concussion in Spor Held in Zurich, November J Ahl Train. 2009; 44(4): NYS Educaion Dep Wrighslaw, Secion 504 and IDEA: Basic Similariies and Differences, Rosenfeld, SJ. NYS Ahleic Trainers Assn Guskiewicz KM, McCrea M, Marshall SW, Canu RC, Randolph C, Barr W, Onae JA, Kelly JP: Cumulaive effecs associaed wih recurren concussion in collegiae fooball players: The NCAA Concussion Sudy. JAMA 290: , Public Schools Ahleic League (NYC Schools) All quesions or commens and requess for inservices/rainings can be direced o: New York Sae Associaion of Independen Schools ThinkSmar! Concussion Managemen Program This manual is provided for informaion purposes and is no inended as a subsiue for medical consulaion wih a qualified healh care professional. We canno be held responsible for any adverse effec ha may arise from he use of or reliance on his manual. hink-smar-concussion-managemen-program.hml Brainline Kids SUNY Youh Spors Insiue ACTive Ahleic Concussion Training for Coaches brain101.orcasinc.com/4000 Special hanks o...grandview High School and Cherry Creek School Disric for heir par in he developmen of REAP Karen McAvoy, PsyD Direcor of he Cener for Concussion Rocky Mounain Hospial for Children Rocky Mounain Youh Spors Medicine Insiue Cenennial Medical Plaza a Dove Valley E. Arapahoe Rd., Suie #300, Cenennial, CO Phone: Fax: Karen.McAvoy@HealhONEcares.com >> REAP hanks: The REAP Advisory Team: Sue Kirelik, MD, Cheryl Melick, MD, Suzanne Rosenberg, MD, Brooke Pengel, MD, Don Gerber, Psy.D, Ann Glang, PhD, Michael Koeser, ATC, MD REAP Pilo School Disrics: Cherry Creek School Disric, Denver Public Schools, Aurora Public Schools, Lileon Public Schools Craig Hospial The TNT (TBI Neworking Teams) Seering Commiee Kelli Janz, Shannon Janz, he Janz/Snakenberg families Ciera Lund and he Lund family The Colorado TBI Trus Fund

17 Your Suden has a Concussion Dae >> Suden s Name As a eacher, you are a very imporan par of he Muli-Disciplinary Team who helps o manage his concussion. Here is some informaion ha will be very helpful o you: Concussions are a raumaic brain injury I akes a child/adolescen an average of 7 o 21 days o recover fully from a concussion Because of he risk of furher brain damage, he mos imporan and mos immediae acion following a concussion is o reduce PHYSICAL aciviy and Reduce MENTAL aciviy The sympoms of a concussion can be seen in your classroom in any of hese four ways: I can affec how a suden migh FEEL PHYSICALLY: (Physical Sympoms) I can affec how a suden migh LEARN: (Cogniive Sympoms) I can affec how a suden migh experience SLEEP or ENERGY LEVELS: (Mainenance Sympoms) I can affec how a suden FEELS EMOTIONALLY: (Emoional Sympoms) Headaches Blurry vision Dizziness Seeing double Disorienaion Nausea Sensiiviy o Sensiiviy o lighs noise Feel menally foggy Easily confused Feel slowed down Slowed speech Difficuly remembering Difficuly concenraing Faigue Drowsiness Excess sleep Too lile sleep Trouble falling or saying asleep Personaliy change Inappropriae emoions Feeling more emoional Irriable Sad Nervous Lack of moivaion The majoriy of sudens recover quie well from a single concussion wih res and reducion of physical and academic demands. This recovery usually akes place over a period of hree weeks. The changes you migh see in a suden following a concussion are generally emporary. However, if you have any concerns abou his suden, please repor hem immediaely o: Name Ph Name Ph Throughou his process, your inpu on how his suden has performed in your classroom is essenial. person(s) lised above. Please coordinae your on-going feedback wih Thank You! page APPENDIX 13

18 APPENDIX Sympom Checklis Name: Assessmen Dae: Dae of Injury: Time of Injury 2-3 Hrs 24 Hrs 48 Hrs 72 Hrs Daily Weekly SYMPTOMS SEVERITY RATING Headache Nausea Vomiing Balance Problems Dizziness Faigue Trouble Falling Asleep Sleeping More han Usual Sleeping Less han Usual Drowsiness Sensiiviy o Ligh Sensiiviy o Noise Irriabiliy Sadness Nervous/Anxious Feeling More Emoional Numbness or Tingling Feeling Slowed Down Feeling like In a Fog Difficuly Concenraing Difficuly Remembering Visual Problems Oher TOTAL Used wih permission from/adaped from he Universiy of Pisburgh Medical Cener and he NATA Graded Sympom Checklis (GSC) NOTE: Sympom Checkliss can be used no only for he iniial evaluaion bu also for each subsequen follow-up assessmen unil all signs and sympoms have cleared a res and during physical exerion. In lieu of simply checking each sympom presen, he ATC can ask he ahlee o grade or score he severiy of he sympoms on a scale of 0-6, where 0 = no presen, 1 = mild, 3 = moderae, and 6 = mos severe.

19 Jimmy McLaughlin 12h Grade My coaches and ahleic rainers helped me feel confiden abou geing back ino spors and helped me know when I was sympom free. Afer my experiences, I was aware of he sympoms of a concussion and knew how o preven i from happening again. I believe ha every school should have concussion screening ess since i would ensure safey for you, and reassurance for your parens, coaches and rainers. Jimmy s Mom I have been a Regisered Nurse for 25 years. I am also a school nurse for Guilderland Cenral School Disric s Pinebush Elemenary. I have four children who are all heavily involved in spors. As we all know, paricipaing in spors does no come wihou is injuries. My son Jimmy had been involved in fooball and wresling since he firs sared high school. Unforunaely, he suffered a concussion during his sophomore year playing fooball. His sympoms included a headache and dizziness, bu hese had subsided unil he winer. During he wresling season, he sympoms resurfaced, and Jimmy had o be excused from all physical aciviies for an addiional wo weeks. Afer Jimmy s second concussion, he experienced difficuly wih refocusing and memory. These difficulies inerfered wih his academics, causing him o miss wo weeks of school. Jimmy s experience has made him become a beer ahlee, and we now fully undersand he need for such programs in caring for school ahlees. I was asonishing o see he many individuals who work o esablish he framework needed o proec our sudens and provide hem wih encouragemen o reurn o playing and learning safely. Paricia McLaughlin JENNIFER SEMEL, MD Medical Direcor, Deparmen of Physical Medicine & Rehabiliaion, S. Charles Hospial & Clinical Professor, Deparmen of Physical Medicine & Rehabiliaion, SUNY a Sony Brook, Sony Brook, NY JENNIFER GRAY, MD Co-Direcor, Concussion Managemen Program, S. Charles Hospial & Clinical Assisan Professor, Physical Medicine and Rehabiliaion, School of Medicine a he Sae Universiy of New York a Sony Brook The REAP Projec is dedicaed in memory of Jacob Snakenberg April 19, 1990 Sepember 19, 2004 To preven fuure loss of life due o concussion HAYLEY QUELLER, MD, PC Co-Direcor, Concussion Managemen Program, S. Charles Hospial & Primary Care Spors Medicine physician, Orhopedic Associaes of Long Island Special hanks o he Kem and McLaughlin families for sharing he sories of heir young ahelees in hopes of saving he lives and brains of ohers.

20 The Family Advocacy, Counseling, and Training Services Program (FACTS) is a BIANYS program providing suppor, advocacy, and linkage o communiy services for individuals who susained a brain injury prior o age 22 and heir families. FACTS Coordinaors are locaed hroughou he sae. BIANYS has also creaed LEARNe, an ineracive compuer-based resource for parens, eachers, clinicians, and sudens. Access i hrough or CONCUSSION MANAGEMENT AND AWARENESS ACT - Summary Chaper 496 of he Laws of New York 2011 Requires: Immediae removal from ahleic aciviies of a suden believed o have susained or who has susained a mild brain injury No reurn unil suden is sympom free for a leas 24 hours; mus be evaluaed and receive wrien permission o reurn by a licensed physician All coaches, physical educaion eachers, nurses and ahleic rainers are required, biennially, o complee a course of insrucion relaing o recogniion of sympoms of mild brain injury and monioring and seeking appropriae medical reamen Parens or ohers in parenal relaionship mus sign permission slip ha conains informaion relaing o concussion NYS Sae Educaion Deparmen, NYS Deparmen of Healh and school disrics mus pos informaion on heir websies Discreionary: School disrics are auhorized o esablish a concussion managemen eam o oversee he implemenaion of concussion policies and procedures in he disric and o be a resource for parens, ahlees, and school saff This program is par of HealhONE s Rocky Mounain Hospial for Children a Presbyerian/ S. Luke s Medical Cener and Rocky Mounain Youh Spors Medicine Insiue. Implemenaion: NYS Sae Educaion Deparmen, in conjuncion wih NYS Deparmen of Healh o promulgae necessary regulaions for implemenaion Effecive dae: July 1, 2012 YouhSporsMed.com RockyMounainHospialForChildren.com