2/3/2019 CONCUSSION The concussion landscape is rapidly evolving. - - PDF document

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2/3/2019 CONCUSSION The concussion landscape is rapidly evolving. - - PDF document

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2/3/2019 CONCUSSION The concussion landscape is rapidly evolving. RECOVERY IN THE CLASSROOM Roni Robinson, MSN, RN, CRNP Concussion Care for Kids: Minds Matter Trauma Program Orthopedic Surgery and Sports Medicine Childrens Hospital of

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CONCUSSION RECOVERY IN THE CLASSROOM

Roni Robinson, MSN, RN, CRNP

Concussion Care for Kids: Minds Matter Trauma Program Orthopedic Surgery and Sports Medicine Children’s Hospital of Philadelphia 3rd Annual School Concussion Conference 2019

1 2

The concussion landscape is rapidly evolving.

THE DIFFICULTY WITH CONCUSSION

3

The straightforward concussion The prolonged concussion Recovers in a few days/weeks Recovers in a few months

“Concussion”

OBJECTIVES

  • When is the right time for the

student to return to school

  • Strategies that can be used in

the classroom to support the concussed student and promote recovery

  • How to best collaborate with

the medical team

4

WHAT’S NEW WITH CONCUSSION?

5

MTBI

  • Best Practices for

Pediatric mTBI

  • 19 sets of

recommendations

  • Diagnosis
  • Prognosis
  • Imaging
  • Sleep Mngt
  • Level of obligation

JAMA Pediatr. doi:10.1001/jamapediatrics.2018.2853 Published online September 4, 2018.

Student

Teachers School Nurse Counselors Social Support Principal Coaches/ ATCs

Return to School Recommendation 15D

JAMA Pediatr. doi:10.1001/jamapediatrics.2018.2853 Published online September 4, 2018.

CDC GUIDELINE ON THE DIAGNOSIS AND MANAGEMENT OF MILD TRAUMATIC BRAIN INJURY AMONG CHILDREN

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  • 15A: Teams should work to advance the student in

school, without exacerbating symptoms

  • 15B: RTS protocols  individualized
  • 15C: Prolonged recovery school should assess

the need for formal supports (504)

  • 15D: Symptoms should be managed by a

multidisciplinary team

  • 15E: Supports should be removed when

appropriate

  • 15F: Prolonged recover refer to mTBI specialist

Rational for INDIVIDUALIZED approach:

Because postconcussive symptoms resolve at different rates in different children after mTBI, individualization of return-to-school programming is necessary.

JAMA Pediatr. doi:10.1001/jamapediatrics.2018.2853 Published online September 4, 2018.

CDC GUIDELINE ON THE DIAGNOSIS AND MANAGEMENT OF MILD TRAUMATIC BRAIN INJURY AMONG CHILDREN

COMMUNICATION BETWEEN MEDICAL TEAM AND SCHOOL

State of PA allows for school nurses to communicate with the medical team. CHOP has placed a higher standard

  • n this law.

We still need guardian consent.

TREATMENT GOALS

  • Avoid repeat head injury

9

TREATMENT GOALS

  • Avoid repeat head injury
  • Minimize the impact on schoolwork

10

TREATMENT GOALS

  • Avoid repeat head injury
  • Minimize the impact on schoolwork
  • Prevent deconditioning

11

Cognitive Physical Social

IS TOO MUCH REST MAKING IT WORSE?

12

Activity Restriction Cascade

DiFazio, Silverberg, et al., Prolonged Activity Restriction After Concussion: Are We Worsening Outcomes? Clin Pediatr (phila), 2016 2016 May;55(5):443-51.

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IT’S OK FOR STUDENTS TO STILL HAVE SYMPTOMS WHEN RETURNING TO SCHOOL

13

Complete cognitive rest until symptom free for 24 hours Relative Rest = Symptom limited activity

How Long to Keep On Cognitive Rest?

  • Beneficial early in the concussion

(first few days)

  • Less beneficial later in the concussion

INITIAL RECOVERY PHASE

14

Day 1 Day 2 Day 3 Day 4

Symptom Limited Rest Minimize missed school days. Return to school.

TRANSLATING OUR FINDINGS TO YOUR CLASSROOM

15

Identify subtle deficits that will impair classroom performance.

CONCUSSION EVALUATION: FOCUS ON VESTIBULAR/VISION

Horizontal & Vertical Saccades Reading Computer work Gaze Stability (Steady Cam) Looking up/down @ board Walking down crowded halls Smooth Pursuits Reading Tracking/ scanning Convergence Looking far to near (up at board and down to take notes)

16

IMPLICATIONS ON ACADEMIC PERFORMANCE

Vestibular and vision problems are prevalent after concussion and cannot be under- appreciated.

17 Master,Clinical Peds 2016 Master, 2017

IMPLICATIONS ON ACADEMIC PERFORMANCE

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Vestibular and vision problems are prevalent after concussion and cannot be under-appreciated. “My eyes hurt.”

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IMPLICATIONS ON ACADEMIC PERFORMANCE

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Vestibular and vision problems are prevalent after concussion and cannot be under-appreciated. “ I have to read the same thing over and over again to understand it.” IMPLICATIONS ON ACADEMIC PERFORMANCE

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Vestibular and vision problems are prevalent after concussion and cannot be under-appreciated. “I studied all night, and then the next day, I can’t remember what I studied” IMPLICATIONS ON ACADEMIC PERFORMANCE

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Vestibular and vision problems are prevalent after concussion and cannot be under-appreciated. “It takes me longer to do the same work.”

VISUAL PROBLEMS AFTER TBI

Dysfunction Substrates Altered refractive state Parasympathetic and sympathetic systems Abnormal version Frontal eye fields, supplementary eye fields, posterior parietal cortex, superior colliculus, visual cortex, pontine reticular formation, cerebellum Abnormal accommodation Visual cortex, parasympathetic system, sympathetic system, cerebellum, midbrain, parietal- temporal area, Edinger-Westphal nucleus Abnormal vergence Cerebellum, pretectal nucleus, superior colliculus, supraoculomotor area,

  • culomotor nucleus, nucleus

tegmenti ponti Photosensitivity Brainstem trigeminal nucleus, noniceptors of the trigeminal subnucleus caudatis Motion sensitivity Middle temporal areas (MT), vestibular apparatus Vestibular defects Vestibular labyrinth, vestibular nerve, vestibular nuclei, cerebellum Visual field defects Retina, optic nerve/tract/chaism, lateral geniculate nucleus, visual cortex, temporal/parietal lobes Visual information processing/perception/visual attention Right parietal lobe, right pre- frontal lobe, right cingulate nucleus, thalamus, striatum

Armstrong, Clin Exp Optom. 2018 Feb 28.

Evelyn goes to play

  • n

sunny day.

  • ut

a

NORMAL READING PATTERN

Evelyn goes to play

  • n

sunny day.

  • ut

a

SACCADIC DYSMETRIA

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Evelyn goes to play

  • n

sunny

  • ut

day.

a

INTERMITTENT BLUR

Evelyn goes to play

  • n

sunny day.

  • ut
  • ut

play day. a

INTERMITTENT DIPLOPIA

COMBINED OCULOMOTOR DYSFUNCTION

Evelyn goes to

  • ut
  • ut
  • n

a sunny playplay day.

VISION CHANGES & MEMORY AFTER CONCUSSION

28

Patients with saccadic eye deficits demonstrated poor performance on memory tests

RETURNING TO SCHOOL

STEP 1: Get them in the building Vital for mental health Make the school environment “User- Friendly”

29

CHALLENGES IN THE SCHOOL ENVIRONMENT

30

DIZZINESS

CONCENTRATION ISSUES

VISUAL PROBLEMS

nervousness

feeling ti tired

Head pressure

Photo/phonophobia

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CONCUSSION IN THE EVERY DAY LIFE OF A STUDENT

31

RETURN TO LEARN: WHERE TO BEGIN?

  • Tier 1 Supports =

Academic Adjustments

  • Informal, flexible, day-

to-day supports

  • Applied when

indicated

  • Lifted when not

needed

32

Multi -Tiered Systems of Support (MTSS)

EDUCATIONAL IMPACT OF MEDICAL DIAGNOSIS

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Medical: Convergence Insufficiency Home: Use desktop instead of laptop Language arts: Preferential seating Audio Books Math: Teacher notes Reduction in # of problems

There is no medical clearance or approval needed for teachers to apply

  • r remove academic

supports as they see fit for student’s in their classroom.

BACK TO SCHOOL: TREATMENT PLAN

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  • Physical school

environment

Return to School

  • Supporting students

to maximize learning

Return to Learn

BACK TO SCHOOL: TREATMENT PLAN

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In order to have a successful RETURN to LEARN, there has to be a successful RETURN TO SCHOOL

BACK TO SCHOOL: TREATMENT PLAN

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There is no “medical clearance” for Return to School.

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GETTING BACK INTO SCHOOL: ENVIRONMENTAL ADJUSTMENTS

  • Preferential seating
  • Earbuds to block

sound

  • Blue blocking

glasses/computer filters

  • Avoiding crowded

hallways/lunchroom

37

GETTING BACK INTO SCHOOL: CREATING A “USER-FRIENDLY” SPACE FOR THE STUDENT

  • Have the student meet with the Concussion

Management Team (CMT)

  • Prevent school avoidance and anxiety
  • Create action plan- individualized, fluid,

flexible and clear

38

BACK IN SCHOOL: WHAT DO THE 1ST FEW DAYS LOOK LIKE?

  • Listen and learn
  • Pace through the day with

breaks

  • Applying adjustments as

needed

  • Starting homework
  • Decrease volume of

workload (quality not quantity)

39

Eliminate non-essential work Reduce semi-essential work

BACK IN SCHOOL: AFTER THE FIRST FEW DAYS

  • Pace through the day with breaks
  • Continue adjustments
  • Lifting adjustments as needed
  • Starting school work
  • Demonstrate mastery in

alternative mode

  • Audit material-base grade on

attendance, participation

  • Can’t do new work & make up

work at the same time

40

BACK TO SCHOOL: TREATMENT PLAN

41

  • Empowering teachers to support the students
  • Helping the student minimize symptom flare-

ups

  • Help the student manage their energy

throughout the day

  • When the student is available for learning, the

teacher can assess the volume of work the student can handle and how best to assess the student’s mastery of a topic

BACK TO SCHOOL TREATMENT PLAN

42

Academic Adjustments

Communicate Expectations

Ensure the student understands the plan

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CONCUSSION: WHAT’S REALLY HAPPENING?

Energy crisis

  • Fluctuating levels of brain

energy wax & wane through the day

  • Impacts

43

Attention Learning Behavior Emotions

HOW DOES CONCUSSION EFFECT PERFORMANCE IN THE CLASSROOM

Concussion symptoms are manifestation

  • f underlying cellular energy

deficit that results in:

44

Mental fatigue Slowed processing speed Short term memory problems

ACADEMIC ADJUSTMENTS: MENTAL FATIGUE

  • Headache- common indicator of inefficient

energy

  • Removal of non-essential work
  • Reduction of semi-essential work
  • STRATEGY

45

Symptom Management

PACING through the day with breaks

ACADEMIC ADJUSTMENTS: SLOW PROCESSING SPEED

  • Slower speech, speed of thinking, writing, etc.
  • Capable of learning, but taking a longer time
  • Removal of non-essential work
  • Reduction of semi-essential work
  • STRATEGY

46

  • Decrease volume
  • Quality, not quantity
  • Comprehension, not

memorization

  • Postponement or

extensions often lead to anxiety Workload Management

ACADEMIC ADJUSTMENTS: READING DIFFICULTIES FROM MENTAL FATIGUE & SLOW PROCESSING

  • Decrease visual crowding
  • Use reading strip
  • OTC reading glasses

47

ACADEMIC ADJUSTMENTS: SHORT TERM MEMORY PROBLEMS

STRATEGIES

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  • Embed new learning into meaningful

past learning

  • Focus on concepts not memorization
  • Consider “audit” learning without

pressure

  • Offer multiple modes of learning audio

books, watching movie, discussion, group projects

Accountability for Grades

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SCHOOL NURSE’S ROLE: THE EXPERT IN THE SCHOOL

  • Acutely:

Recognize the signs & symptoms Effectively evaluate the student Make decisions about referral if needed

49

McNeal L, Selekmen J. Guidance for Return to Learn after Concussion NASN Sch Nurse. 2017 Sep;32(5):310-316

SCHOOL NURSE’S ROLE: THE EXPERT IN THE SCHOOL

Return to School/Return to learn Process:

Communication team is key Create an Individualize Health Plan ”Tier 1 Level supports”

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School Nurse

Partner with CMT

Advocate for Student Member

  • f CMT

Partner with ATC

Routine Student Assessment

Partner with Family

SCHOOL NURSE’S ROLE: THE EXPERT IN THE SCHOOL

  • Students check in on a

routine basis

  • Symptoms check lists

Are we making it worse?

  • Daily concussion symptom

inventory

  • Strict Concussion

Protocols?

51

KNOW YOUR RESOURCES

  • School Re-Entry Programs for brain injury
  • Services offered by the IU
  • Check with your state’s Brain Injury

Association

52

THE ROAD TO RECOVERY

53 54

“This is too hard, it seems hopeless.”

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55

“It will be impossible to make up all I missed.”

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“I will never get into college.”

THE ROAD TO RECOVERY

  • Prolonged concussions

cause anxiety, mood changes

  • These symptoms of

concussion also increase risk of depression

  • Lifestyle change
  • Cognitive changes
  • Sleep disturbances
  • Headaches/pain
  • Loss of their “ideal self”

57

Alterations in Cognitive Processing:

  • Greater impulsivity
  • Poorer problem-solving
  • Greater emotional lability
  • Frustrations with cognitive

limitations

58

WE ALL HAVE A ROLE TO PLAY

59

The concussion landscape is rapidly evolving.

How will we keep up?

SUMMARY

  • School NursePivotal role for

concussion recovery for the student

  • Know your tools, know your student,

know how it all fits together

  • The Secret Sauce: The right amount
  • f activity, behavior regulation &

matching the volume of work to the energy

  • Recognize & treat BH issues
  • Expose and recover: are words to

live by

  • Concussion is treatable….but it

requires patience

  • Best Practice Individualized

Concussion Plan that is flexible and fluid

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CHOP MINDS MATTER TEAM

61 Christina Master, MD Olivia Podolak, MD Matt Grady, MD Michael Nance, MD Brian Vernau, MD Noami Brown, MD Lindsey Calandra, CRNP Roni Robinson, CRNP Eileen Storey Research Asst. Kate Easby, ATC Andrea Mallon, RN Concussion Nurse Navigator Christopher Renjilian, MD

robinsonr@chop.edu

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Concussion in Collegiate Athletes and US Military Service Academy Members: The NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium Structure and Methods. Sports Med, 2017. Jul47(7): 1427-1451

  • Arbogast, KB, Curry, AE, Pfeiffer, MR ,Zonfrillo MR, Haarbauer-Krupa, J, Breiding, MJ, Coronado, VG, Master, CL.. Point of Health Care Entry for Youth

With Concussion Within a Large Pediatric Care Network. JAMA Pediatr, 2016, Jul 5; 170(7).

  • Howell DR, Lynall RC, Buckley TA, Herman DC., Neuromuscular control deficits and the risk of subsequent injury after concussion: a scoping review.

Sports Med. 2018. doi: 10.1007/s40279-018-0871-y. [Epub ahead of print]

  • Moore, BM, Adams, JT, Barakatt, E. Outcomes Following a Vestibular Rehabilitation and Aerobic Training Program to Address Persistent Post-Concussion

Symptoms.J Allied Health. 2016, Winter; 45(4): e59-e68.

  • Cheever, KM, McDevitt, J, Tierney, R, Wright, WG. Concussion Recovery Phase Affects Vestibular and Oculomotor Symptom Provocation. J Sports Med,

2018 Feb;39(2):141-147

  • Bacon, CEW, Kay, MC, McLeod, TCV, Athletic Trainers' Roles and Responsibilities Regarding Academic Adjustments as Part of the Concussion-

Management Process in the Secondary School Setting. Jn Athlet Train.. 2017 Oct;52(10):937-945. doi: 10.4085/1062-6050-52.7.02.

  • Wallace, J, Covassin, T, Nogle, S, Gould, D, Kovan, J. Concussion Knowledge and Reporting Behavior Differences Between High School Athletes at Urban

and Suburban High Schools. J Sch Health, 2017 Sep;87(9):665-674

  • Crovassin, T, Moran, R, Elbin, RJ, Sex Differences in Reported Concussion Injury Rates and Time Loss From Participation: An Update of the National

Collegiate Athletic Association Injury Surveillance Program From 2004-2005 Through 2008-2009.J Athl Train, 2016 Mar;51(3):189-94. doi: 10.4085/1062-6050-51.3.05. Epub 2016 Mar 7.

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