Return to Learn after Concussion Training: Coming to Orange County in August

Are you an educator, administrator, counselor, or a medical professional who works with student-athletes who are returning to the classroom environment after a concussion?

Do you have concerns, knowledge gaps, frustrations, or just plain wish to see how others manage these challenging situations?

Well, I wish to bring to your attention a  collaborative effort with the Orange County Concussion Consortium and the Orange County Department of Education to promote an important Return to Learn after Concussion Conference on August 29, 2015 featuring renown expert Brenda Eagan Brown.

Target Audience:

• School Principals, Vice Principals and other Administrators
• Classroom Teachers
• Curriculum Specialists
• School Nurses
• School Psychologists
• School Counselors
• Special Education Specialists
• Speech and Language Therapists
• Athletic Trainers
• Concussion medical experts
• Strongly recommend forming school-based teams to attend and maximize the learning experience

Please share this with colleagues and register early as seats are limited!

Thoughts on California Interscholastic Federation Concussion Return Protocol

Right before California Assembly Bill 2127 became law on January 1, 2015, I wrote on this blog many questions remained unanswered about certain provisions, namely clarifying what is meant by "no less than a seven day" return progression, when does this seven day period begin, and a better definition of appropriate supervision during this period.

Today, after reviewing the recently released California Interscholastic Federation (CIF) Concussion Return to Play Protocol, it is now readily apparent that the intent of the law was to ensure that if an athlete was concussed let's say on a Friday night, that they will not be able to return to play the following Friday night.

This comes as no great surprise to many of us in the sports medicine community and serves to bring uniformity to something that we had suspected since the bill was signed into law.

There are several other provisions of the Return to Play progression that should be of unique interest, and I will list them below along with my professional comments:

• Return to play cannot be sooner than 7 days AFTER the diagnosis of a concussion by an physician MD/DO
  • Now we know when the "clock can start" and what concerns me is not so much the sports with one game a week, but those with multiple games a week.
  • If a football player is concussed on Friday night, having the physician evaluation the following Monday or even Thursday doesn't have a real time sensitivity since that athlete is out for that next week's game and still has the seven day period potentially available to play in the following weeks game.
  • However, let's take the case of a basketball player with a tournament that involves key games possibly 8-9 days after a concussion. There might be pressure placed on the physician to see that athlete ASAP to get the clock started for a potential return in that 8-9 day period
• No physical activity for at least 2 full symptom-free days AFTER you have seen a physician 
  • Given the emphasis on the no return within a full week after a concussion, can certainly see why this element was put into place.
  • Does limit the judgement of medical teams to allow light, low-risk activities that might be well-tolerated in the initial post-concussion period and may also actually assist in that recovery.
• A certified athletic trainer (ATC), physician, or identified concussion monitor (e.g., coach, athletic director), must initial each stage successfully passed
  • Leads to an increase in the paper trail but also makes each school responsible for monitoring a step-wise return to play and not just allowing a full immediate return to sport. 
  • Hopefully this provision will further underscore the important role of a certified athlete trainer on a school campus. For those schools that don't have one, this might serve as a strong motivator to find necessary resources to support the hire of an ATC to help maintain compliance with this new law.
•  Minimum of 6 days to pass (non-contact) Stages I and II. Prior to beginning (contact) State III, please make sure that written physician (MD/DO) clearance for return to play, after successful completion of Stages I and II, has been given to your school’s concussion monitor. 
  • That 6 day minimum again written with a direct eye on football and not having an athlete return for that next game after a concussion
  • Here's another spot where having an ATC can make the process easier- as a physician, if I have a strong working relationship with an ATC, I might not need to see the athlete back in my office before allowing return to contact if the ATC is comfortable with the return protocol and progress of the individual athlete.
  • Now, if there is no ATC on campus, stronger chance that I will require an office visit between non-contact and contact return.
• MANDATORY: You must complete at least ONE contact practice before return to competition. (Highly recommend that Stage III be divided into 2 contact practice days as outlined above.) 
  • Remember that AB 2127 also limits full contact  practices to only 2 ninety minute sessions per week. 
  • Curious to see how a return to play that recommends 2 contact sessions works out with these new contact practice limitations

I will close out this post with a  passionate request to CIF and the sports and school communities: despite any concerns or disagreements, this protocol is now in place and thus must be publicized, discussed and shared through multiple mediums to get the word out to all coaches, athletes, parents, administrators, and medical providers. . I can honestly say that with past state or CIF concussion policy updates, I was shocked at how often reasonable, involved, and usually well-informed colleagues were unaware or ignorant of these changes. If all schools are following the same protocol, there will be more universal acceptance of this new policy, so CIF cannot passively oversee dissemination, it must take a very active and vocal role to increase the appropriate use and eventual greater acceptance of this new protocol.

Studying Role of High School Principals in Return to Learn after Concussion

If there isn't enough frustration and feeling of being overwhelmed after suffering a concussion, the process of returning a student back to academic work can only seem to magnify those concerns.

While return-to-play progression protocols have been established to assist in getting athletes back to sport, similar return-to-learn programs have lagged behind.  The sheer complexity of  meeting particular needs and schedule demands of each student requires an individualized plan created with appropriate understanding of expectations and optimal communication between medical professionals, families and educators.

Often, recommendations include  designating a point person who can advocate for the student and family by communication with fellow educators and monitor of student progress.  This same person might also provide on-going dialogue with outside medical providers. However, finding a person with appropriate knowledge and desire to accept and carry out these roles can be difficult. 

A school-based concussion management and response plan can provide further framework to delineate expectations, potential adjustments, and roles, though the actual implementation and utility of such plans has not received much study.

Given the common findings of frustration and lack of apparent coordination in the return to learn process, I was excited to review the article HIgh School Principals' Resources, Knowledge, and Practices regarding the Returning Student with Concussion  in an effort to gain unique and previously unreported insight into school-based resources and management strategies.

Using a cross-sectional computer-based survey of 465 urban, suburban, and rural public high school principals in the state of Ohio, key findings of this study included:

• Just over 1/3 of the principals had completed some form of concussion training in the past year, with those who completed such training have higher self-reported concussion knowledge scores and were more likely to have provided or supported concussion training for school faculty who were not directly involved with youth sports
• When identifying a point person, athletic trainers were most often reported, but about 1/5 of respondents did not know or designate a point person at their school. Schools that identified  more than one point person tended to  have more students, a principal with higher self-reported concussion knowledge, and to have a full or part-time athletic trainer.
• Athletic trainers were reported as the main agents of communication with medical professionals for concussed student-athletes, while school nurses and counselors assumed this role for concussed students who were not athletes. Principals, assistant principals, and guidance counselors assumed the primary role of communication with parents for all students  (regardless of athlete status).
•  When asked to respond to a list of short-term classroom adjustments commonly recommended for concussed students, over 90% of principals agreed with all or most of them, with just over 30% requiring a health care provider note to initiate the adjustments.
• Several principals reported a school response-to-intervention (RTI) team to assess student needs and to develop an intervention plan in terms of academic adjustments and accommodations.
• About 1/3 of the schools had a written concussion plan, with 75% of those plans addressing academic adjustments and accommodations.

How can we use these findings to better assist our concussed students in their effort to return to the classroom?

• A principal with concussion knowledge is essential- thus ensure more (and hopefully higher quality) concussion training for principals, which could then translate to more training for school personnel, the identification of point persons to assist concussed students, and better communication between principals and the parents of a concussed athlete.
  • Potential avenues include Internet modules from the National Federation of State High School Associations and the Centers for Disease Control and Prevention.
• An athletic trainer is essential- thus ensure that every high school campus has a  certified athletic trainer acting as an advocate for concussed students and being on campus for part/all of the academic day (not just for after-school activities) to foster relationships with teachers and help monitor student developments.
• An intervention team is essential to initiate academic adjustments early after a concussion, preferably without the absolute need of a medical provider note to reduce any obstacles.
• Providing a concussion management plan that delineates roles and expectations and is shared with all key parties (students, school personnel, families and medical providers) to provide education and on-going assessment of the utility of the plan.

What other recommendations do you have to assist concussed students return to learn? Do these recommendations seem reasonable and practical?