How every family, school and medical professional can creae a Communiy-Based Concussion Managemen Program REAP The Benefis of Good Concussion Managemen Cener for Concussion The REAP Projec Reduce Educae Accommodae Pace Auhored by Karen McAvoy, PsyD
Rocky Mounain Youh Spors Medicine Insiue Cener for Concussion Cenennial Medical Plaza a Dove Valley 14000 E. Arapahoe Rd., Suie #300 Cenennial, CO 80112 Phone: 720.979.0840 Fax: 303.690.5948 Endorsed by: Auhored by: Karen McAvoy, PsyD Original funding from: COPYRIGHT 2011 KAREN MCAVOY ALL RIGHTS RESERVED Las revised March 2011
The REAP Projec which sands for Reduce Educae Accommodae Pace is a communiy-based model for Concussion Managemen ha was developed in Colorado. e early origins of REAP sem from he dedicaion of one ypical high school and i's surrounding communiy. A er 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. e ne became sronger when parens and communiy medical professionals also worked ogeher o coordinae care and recovery from concussion. e lessons learned from his ragic even are ha a Muli-Disciplinary Team approach is he foundaion of good Concussion Managemen. e Muli-Disciplinary Teams: Family Team School Physical Team School Academic Team Medical Team ese eams work closely o wach and care for he suden/ahlee during his or her enire recovery from concussion. e wriing of REAP was funded by an Educaion Gran from he Colorado Traumaic Brain Injury Trus Fund in 2009. From 2009 o 2010, REAP was piloed a eigh HealhONE Emergency Deparmens and four school disrics. In one year (2009-2010), he REAP projec received more han 150 referrals of sudens/ahlees evaluaed in Emergency Deparmens (ED) for concussion. A er 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. e 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 www.youhsporsmed.com. 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 RockyMounainHospialForChildren.com
Medical noe from Sue Kirelik, MD, Direcor of Pediaric Emergency Medicine, Rocky Mounain Hospial for Children a Sky Ridge Medical Cener, REAP Medical Advisor. > > > > > > > > > Newer recommendaions are ha children and eens should be reaed much more conservaively han aduls when i comes o concussion. The developing brain is very differen from he adul brain; i is much more likely o manifes sympoms laer and have longer erm problems when injured, especially if he child is no allowed o res and recover. Because each concussion and each child is differen, grading scales are no longer recommended. Care for each child and each concussion mus be individualized. 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.
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 >> e 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. e unique perspecive from each of hese various eams is essenial! >> e firs day of he concussion is considered Day 1. e firs day of recovery also sars on Day 1. e 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
page 2 Rocky Mounain Youh Spors Medicine Insiue 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: www.cdc.gov/concussion/ >> 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: www.cdc.gov/concussion/ >> 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:www.cdc.gov/concussion/headsup/schools.hml 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: www.cdc.gov/concussion/headsup/physicians_ool_ki.hml REDUCE EDUCATE ACCOMMODATE PACE SPECIAL CONSIDERATIONS RESOURCES APPENDIX
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! Jake Snakenberg April 19, 1990 - Sepember 19, 2004 In he Fall of 2004, Jake Snakenberg was a freshman fooball player a Grandview High School. He likely susained a concussion in a game he week prior, however, he did no fully undersand ha he had experienced a concussion and he did no repor his sympoms o anyone. One week laer, Jake ook a ypical hi in a game, collapsed on he field and never regained consciousness. Jake passed away from Second Impac Syndrome on Sepember 19, 2004. 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. is 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 e 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
page 4 EDUCATE Rocky Mounain Youh Spors Medicine Insiue 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. erefore, i is essenial ha everyone undersand, recognize and be mindful of ALL sympoms relaed o concussion. Every sympom is imporan. e 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 orough sympom monioring is he key o good managemen. erefore, 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 head-ache, 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!
>> 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. ose 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 REAP canno sress enough managemen of concussion requires ha here is an equal parnership beween he members of he school eam who manage physical reducion and hose who manage cogniive reducion. See ACCOM- MODATE for how o reduce cogniive load. e 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) o en 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 o en 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 Teams? 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
page 6 EDUCATE Rocky Mounain Youh Spors Medicine Insiue In order o obain a common language beween all Concussion Managemen Team members, an objecive measure of sympoms has been found o be helpful. erefore, 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. is allows for immediae accommodaions/adjusmens o be made. In our experience, he majoriy of communicaion occurs beween eam members via phone or email. Formal meeings have rarely been necessary. e 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. a 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. e REAP model does no depend upon more Ciera was 15 years old when she suffered a concussion while playing baskeball. Her sympoms of passing ou, consan headaches and faigue plagued her for he remainder of her freshman year. A few accommodaions helped Ciera successfully complee he school year. I really helped me when my eachers had class noes already prined ou. Tha way I could jus highligh wha he eacher was emphasizing and focus on he concep raher han rying o ake noes. Since having a brain injury, I don really see words on he board, I jus see leers. Therefore, having he noes beforehand akes some of he frusraion off of me and I am able o concenrae and reain wha is being augh in class. Being able o res in he middle of he day is also very imporan for me. I become very faigued afer a morning of my rigorous classes, so my counselors have helped me adjus my schedule which allows me some down ime so I can keep going hrough my day. Lasly, aking ess in a differen place such as he conference room or eacher s office has helped a grea deal. CIERA LUND resources. Insead i depends upon he srengh of a srongly educaed and well-coordinaed eam. e 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! Medical Box Monday Morning Concussion Sympoms of a concussion may no develop immediaely afer he injury. In fac, sympoms may appear hours or even days laer. One common scenario is when a suden/ahlee suffers a concussion on a Friday or Saurday, perhaps during a sporing even. The suden/ahlee may have a quie weekend wih few or no sympoms. I is no unil hey reurn o school on Monday, when he hinking demands from schoolwork increases, does he suden/ahlee begin o experience sympoms. I is imporan o recognize ha hese sympoms are relaed o he concussion. Sudens, parens and educaors mus learn o wach for delayed sympoms. In addiion, hey mus pay aenion o he aciviies ha worsen hose sympoms afer hey appear. -Sue Kirelik, MD, Direcor of Pediaric Emergency Medicine, Rocky Mounain Hospial for Children a Sky Ridge Medical Cener, REAP Medical Advisor
>> 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. e 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
page 8 ACCOMMODATE Rocky Mounain Youh Spors Medicine Insiue Mos Common Thinking Cogniive Problems Pos-Concussion And suggesed accommodaions Areas of concern Suggesed Accommodaions School Team Educaors When an ahlee is injured, he coaches keep he ahlee engaged wih he eam (by aending pracices, raveling wih he eam) even when he ahlee canno play. This concep of keeping he suden involved and engaged in academics, in spie of he concussion, is very imporan. While cuing back on he cogniive load, he school eam mus devise a plan o keep he suden academically condiioned and engaged in learning hroughou he enire hree-week recovery period. Faigue, specifically Menal Faigue Difficuly concenraing Feels like being in a fog > Schedule sraegic res periods. Do no wai unil he suden s over-iredness resuls in an emoional meldown. > Adjus he schedule o incorporae a 15-20 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. Medical Box 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 www.cokidswihbraininjury.com. 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. >> More in-deph informaion and recommendaions can be found in he BrainSTARS Manual (see RESOURCES)
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. >> Does 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
page 10 PACE Rocky Mounain Youh Spors Medicine Insiue 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 1 2 3 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 - 10-15 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, 20-30 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 2008. J Ahl Train. 2009;44(4):434-448
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 www.cokidswihbraininjury.com. Oher brain injury resources are lised in he RESOURCES secion. Medical Box >> 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. e 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 gi. 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). Sudens who have Aenion Deficis, Learning Disabiliies, a hisory of migraine headaches, sleep disorders, depression or oher psychiaric disorders may have more difficuly recovering from a concussion. Sudens who have had muliple concussions, a recen prior concussion or who are geing sympomaic afer less impac may be a risk for long-erm complicaions. Research suppors he fac ha a person who susains one concussion is a higher risk for susaining a fuure concussion. 7 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 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
page 12 Rocky Mounain Youh Spors Medicine Insiue RESOURCES Resources Ceners for Disease Conrol (CDC) www.cdc.gov 1-800-CDC-INFO REFERENCES Colorado TBI Trus Fund www.bicolorado.org 303-866-4779 1. 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; 58:275-286 CO Child/Adolescen Brain Injury www.cokidswihbraininjury.com 2. 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);546-53.6. Brain Injury Associaion of Colorado (BIAC) www.biacolorado.org 303-355-9969 3. Langlois JA, Ruland-Brown W, Wald MM. The epidemiology and impac of raumaic brain injury: a brief overview. J Head Trauma Rehabil. 2006; 21:375-78.2. 4. Canu RC. Second impac syndrome. Clin Spors Med. 1998; 17:37-44. Brain Injury Associaion of America (BIAA) www.biausa.org 1-800-444-6443 5. 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 2008. J Ahl Train. 2009; 44(4):434-448. Colorado High School Aciviies Associaion (CHSAA) www.chsaa.org 303-341-5050 6. Wrighslaw, Secion 504 and IDEA: Basic Similariies and Differences, Rosenfeld, SJ. www.wrighslaw.com/advoc/aricles/504_idea_rosenfeld.hml. Colorado Deparmen of Educaion (CDE) www.cde.sae.co.us 303-866-6739 7. 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: 2549 2555, 2003. BrainSTARS Naional Associaion of Ahleic Trainers (NATA) Naional Federaion of Sae High School Associaions Coaches Training: (free, online coach-raining sessions) >> All quesions or commens and requess for inservices/rainings can be direced o: 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 14000 E. Arapahoe Rd., Suie #300 Cenennial, CO 80112 Phone: 720.979.0840 Fax: 303.690.5948 Karen.McAvoy@HealhONEcares.com www.naa.org www.journalofahleicraining.org 720-777-5470 nfhs.org 317-972-6900 Naional Federaion of Sae High School Associaions ACTive Ahleic Concussion Training for Coaches www.nfhslearn.org concussion.orcasinc.com >> Special hanks o... Grandview High School and Cherry Creek School Disric for heir par in he developmen of REAP >> 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 This manual is available in Spanish upon reques. This program is par of HealhONE s Rocky Mounain Hospial for Children and Rocky Mounain Youh Spors Medicine Insiue.
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 e 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 e majoriy of sudens recover quie well from a single concussion wih res and reducion of physical and academic demands. is recovery usually akes place over a period of hree weeks. e 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 E-mail Name Ph E-mail roughou his process, your inpu on how his suden has performed in your classroom is essenial. Please coordinae your on-going feedback wih person(s) lised above. ank You! page APPENDIX 13
Rocky Mounain Youh Spors Medicine Insiue 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 0 1 2 3 4 5 6 Nausea 0 1 2 3 4 5 6 Vomiing 0 1 2 3 4 5 6 Balance Problems 0 1 2 3 4 5 6 Dizziness 0 1 2 3 4 5 6 Faigue 0 1 2 3 4 5 6 Trouble Falling Asleep 0 1 2 3 4 5 6 Sleeping More han Usual 0 1 2 3 4 5 6 Sleeping Less han Usual 0 1 2 3 4 5 6 Drowsiness 0 1 2 3 4 5 6 Sensiiviy o Ligh 0 1 2 3 4 5 6 Sensiiviy o Noise 0 1 2 3 4 5 6 Irriabiliy 0 1 2 3 4 5 6 Sadness 0 1 2 3 4 5 6 Nervous/Anxious 0 1 2 3 4 5 6 Feeling More Emoional 0 1 2 3 4 5 6 Numbness or Tingling 0 1 2 3 4 5 6 Feeling Slowed Down 0 1 2 3 4 5 6 Feeling like In a Fog 0 1 2 3 4 5 6 Difficuly Concenraing 0 1 2 3 4 5 6 Difficuly Remembering 0 1 2 3 4 5 6 Visual Problems 0 1 2 3 4 5 6 Oher 0 1 2 3 4 5 6 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.
JOHN POLOUSKY, MD Surgical Direcor BROOKE PENGEL, MD Medical Direcor KAREN MCAVOY, PSYD Cener for Concussion 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 Rocky Mounain Youh Spors Medicine Insiue is a comprehensive service for he prevenion, reamen and rehabiliaion of spors injuries in children and adolescens. The Youh Spors Medicine Insiue is led by John Polousky, MD, Surgical Direcor and Brooke Pengel, MD, Medical Direcor. The Cener for Concussion is led by Karen McAvoy, PsyD.
This program is par of HealhONE s Rocky Mounain Hospial for Children a Presbyerian/S. Lulke s Medical Cener and Rocky Mounain Youh Spors Medicine Insiue. Rocky Mounain Youh Spors Medicine Insiue is a comprehensive service for he prevenion, reamen and rehabiliaion of spors injuries in children and adolescens ha include: sae-of-he-ar physicians pracice designed for care of he suden ahlee specialy care for paiens from he skeleally immaure hrough young adul a commimen o ousanding communicaion wih paiens, families and referring physicians full-specrum musculoskeleal imaging capabiliies comprehensive concussion managemen program wih communiy oureach services and educaion o schools and spors clubs spors injury and performance research same-day availabiliy for paien consulaion YouhSporsMed.com Cener for Concussion a Rocky Mounain Youh Spors Medicine Insiue 14000 E. Arapahoe Rd., Suie #300 Cenennial, CO 80112 Phone: 720.979.0840 Fax: 303.690.5948 RockyMounainHospialForChildren.com