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

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 Children’s Hospital of Philadelphia 3 rd Annual School Concussion Conference 2019 1 2 THE DIFFICULTY WITH CONCUSSION OBJECTIVES • When is the right time for the The prolonged The straightforward student to return to school concussion concussion • Strategies that can be used in the classroom to support the concussed student and promote “Concussion” recovery • How to best collaborate with Recovers in a few months Recovers in a few days/weeks the medical team 3 4 MTBI CDC GUIDELINE ON THE DIAGNOSIS AND • Best Practices for WHAT’S NEW WITH MANAGEMENT OF MILD TRAUMATIC Pediatric mTBI CONCUSSION? BRAIN INJURY AMONG CHILDREN • 19 sets of recommendations Return to School • Diagnosis Recommendation 15D Teachers • Prognosis • Imaging Coaches/ School • Sleep Mngt Nurse ATCs • Level of obligation Student Principal Counselors Social Support JAMA Pediatr . doi:10.1001/jamapediatrics.2018.2853 Published online September 4, 2018 . JAMA Pediatr. doi:10.1001/jamapediatrics.2018.2853 5 Published online September 4, 2018. 1

2/3/2019 CDC GUIDELINE ON THE DIAGNOSIS AND COMMUNICATION BETWEEN MANAGEMENT OF MILD TRAUMATIC MEDICAL TEAM AND SCHOOL BRAIN INJURY AMONG CHILDREN Rational for • 15A: Teams should work to advance the student in INDIVIDUALIZED school, without exacerbating symptoms approach: • 15B: RTS protocols  individualized Because postconcussive • 15C: Prolonged recovery  school should assess symptoms resolve at different rates in different children the need for formal supports (504) after mTBI, • 15D: Symptoms should be managed by a individualization of multidisciplinary team return-to-school • 15E: Supports should be removed when programming is necessary. appropriate State of PA allows for school nurses to • 15F: Prolonged recover  refer to mTBI specialist communicate with the medical team. CHOP has placed a higher standard on this law. We still need guardian consent. JAMA Pediatr. doi:10.1001/jamapediatrics.2018.2853 Published online September 4, 2018. TREATMENT GOALS TREATMENT GOALS • Avoid repeat head injury • Avoid repeat head injury • Minimize the impact on schoolwork 9 10 IS TOO MUCH REST MAKING IT WORSE? TREATMENT GOALS • Avoid repeat head injury • Minimize the impact on schoolwork • Prevent deconditioning Activity Restriction Cascade Cognitive Physical Social DiFazio, Silverberg, et al., Prolonged Activity Restriction After Concussion: 11 12 Are We Worsening Outcomes? Clin Pediatr (phila), 2016 2016 May;55(5):443-51. 2

2/3/2019 IT’S OK FOR STUDENTS TO STILL HAVE SYMPTOMS WHEN INITIAL RECOVERY PHASE RETURNING TO SCHOOL Symptom Minimize missed school days. Limited Rest Return to school. Relative Rest Complete Day 1 Day 2 Day 3 Day 4 = Symptom cognitive rest limited activity until symptom free for 24 hours How Long to Keep On Cognitive Rest? Beneficial early in the concussion • (first few days) • Less beneficial later in the concussion 13 14 CONCUSSION EVALUATION: TRANSLATING OUR FINDINGS FOCUS ON VESTIBULAR/VISION TO YOUR CLASSROOM Horizontal & Reading Computer work Vertical Saccades Gaze Stability Looking Walking down (Steady Cam) up/down @ crowded halls board Smooth Reading Tracking/ Pursuits scanning Convergence Looking far to near (up at board Identify subtle and down to take notes) deficits that will impair classroom performance. 15 16 IMPLICATIONS ON ACADEMIC IMPLICATIONS ON ACADEMIC PERFORMANCE PERFORMANCE Vestibular and vision problems are prevalent Vestibular and vision problems are after concussion and cannot be under- appreciated. prevalent after concussion and cannot be under-appreciated. “My eyes hurt.” Master,Clinical Peds 2016 17 18 Master, 2017 3

2/3/2019 IMPLICATIONS ON ACADEMIC IMPLICATIONS ON ACADEMIC PERFORMANCE PERFORMANCE Vestibular and vision problems are Vestibular and vision problems are prevalent after concussion and cannot be prevalent after concussion and cannot be under-appreciated. under-appreciated. “I studied all night, and “ I have to read the same then the next day, I can’t thing over and over again to remember what I understand it.” studied” 19 20 Dysfunction Substrates IMPLICATIONS ON ACADEMIC Parasympathetic and sympathetic VISUAL PROBLEMS Altered refractive state systems Frontal eye fields, supplementary AFTER TBI PERFORMANCE eye fields, posterior parietal Abnormal version cortex, superior colliculus, visual cortex, pontine reticular formation, cerebellum Visual cortex, parasympathetic Vestibular and vision problems are system, sympathetic system, Abnormal accommodation cerebellum, midbrain, parietal- temporal area, Edinger-Westphal prevalent after concussion and cannot be nucleus Cerebellum, pretectal nucleus, superior colliculus, under-appreciated. Abnormal vergence supraoculomotor area, oculomotor nucleus, nucleus tegmenti ponti Brainstem trigeminal nucleus, noniceptors of the trigeminal Photosensitivity subnucleus caudatis “It takes me longer to do the same work.” Middle temporal areas (MT), Motion sensitivity vestibular apparatus Vestibular labyrinth, vestibular Vestibular defects nerve, vestibular nuclei, cerebellum Retina, optic nerve/tract/chaism, Visual field defects lateral geniculate nucleus, visual cortex, temporal/parietal lobes Visual information Right parietal lobe, right pre- processing/perception/visual frontal lobe, right cingulate attention nucleus, thalamus, striatum 21 Armstrong, Clin Exp Optom. 2018 Feb 28. SACCADIC DYSMETRIA NORMAL READING PATTERN Evelyn goes out to play on a Evelyn goes out to play on a sunny day. sunny day. 4

2/3/2019 INTERMITTENT BLUR INTERMITTENT DIPLOPIA Evelyn goes out out to play play on a Evelyn goes out to play on a sunny day. day. sunny day. VISION CHANGES & MEMORY COMBINED OCULOMOTOR DYSFUNCTION AFTER CONCUSSION Patients with saccadic eye deficits demonstrated poor performance on memory tests Evelyn goes playplay out out to on a sunny day. 28 CHALLENGES IN THE SCHOOL ENVIRONMENT RETURNING TO SCHOOL STEP 1: Get them in the building DIZZINESS  Vital for mental health Photo/phonophobia  Make the school environment “User - Friendly” CONCENTRATION ISSUES feeling ti tired VISUAL PROBLEMS nervousness Head pressure 29 30 5

2/3/2019 CONCUSSION IN THE EVERY RETURN TO LEARN: DAY LIFE OF A STUDENT WHERE TO BEGIN? Multi -Tiered • Tier 1 Supports = Systems of Support Academic Adjustments (MTSS) • Informal, flexible, day- to-day supports • Applied when indicated • Lifted when not needed 31 32 EDUCATIONAL IMPACT OF BACK TO SCHOOL: TREATMENT PLAN MEDICAL DIAGNOSIS Medical: Convergence Math: Return • Physical school Insufficiency Teacher notes environment Reduction in # of to School problems Language arts: Return • Supporting students Preferential Home: to maximize seating Use desktop to Learn Audio Books learning instead of laptop There is no medical clearance or approval needed for teachers to apply or remove academic s upports as they see fit for student’s in their classroom. 33 34 BACK TO SCHOOL: TREATMENT PLAN BACK TO SCHOOL: TREATMENT PLAN In order to have a successful RETURN to LEARN, There is no there has to be “medical clearance” a successful for RETURN TO Return to School. SCHOOL 35 36 6

2/3/2019 GETTING BACK INTO SCHOOL: GETTING BACK INTO SCHOOL: CREATING A “USER - FRIENDLY” SPACE ENVIRONMENTAL ADJUSTMENTS FOR THE STUDENT • Preferential seating • Have the student meet with the Concussion • Earbuds to block Management Team (CMT) sound • Prevent school avoidance and anxiety • Blue blocking • Create action plan- individualized, fluid, glasses/computer flexible and clear filters • Avoiding crowded hallways/lunchroom 37 38 BACK IN SCHOOL: WHAT DO THE 1 ST BACK IN SCHOOL: AFTER THE FIRST FEW DAYS LOOK LIKE? FEW DAYS • Listen and learn • Pace through the day with breaks • Continue adjustments • Pace through the day with breaks • Lifting adjustments as needed • Applying adjustments as • Starting school work needed • Demonstrate mastery in alternative mode • Starting homework • Audit material-base grade on • Decrease volume of attendance, participation workload (quality not • Can’t do new work & make up quantity) work at the same time Eliminate non-essential work Reduce semi-essential work 39 40 BACK TO SCHOOL TREATMENT PLAN BACK TO SCHOOL: TREATMENT PLAN Academic Communicate Adjustments Expectations • Empowering teachers to support the students • Helping the student minimize symptom flare- ups • Help the student manage their energy throughout the day Ensure the student • When the student is available for learning , the understands the plan teacher can assess the volume of work the student can handle and how best to assess the student’s mastery of a topic 41 42 7