8/8/17. A Collaborative Concussion Culture Karen McAvoy, PsyD. Second Impact Syndrome (SIS) REAP The Benefits of Good Concussion Management

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8/8/17 A Collaborative Concssion Cltre Karen McAvoy, PsyD Agst 10,

professional can create a Commnity-Based Concssion Management Program

Lke s Center for Concssion REAP SM Remove/Redce Edcate A

1 8/8/17 A Collaborative Concssion Cltre Karen McAvoy, PsyD Agst 10, 2017 Second Impact Syndrome (SIS) How every family, school and medical professional can create a Commnity-Based Concssion Management Program REAP The Benefits of Good Concssion Management SM At Presbyterian/St. Lke s Center for Concssion REAP SM Remove/Redce Edcate A djst/accommodate Pace Athored by Karen McAvoy, PsyD RockyMontainHospitalforChildren.com 1

Seamless System of Commnication and Collaboration A Mlti-Disciplinary Team Team members who provide mltiple perspectives of the stdent/athlete AND Team members who provide mltiple sorces of data

2 Seamless System of Commnication and Collaboration A Mlti-Disciplinary Team Team members who provide mltiple perspectives of the stdent/athlete AND Team members who provide mltiple sorces of data Whowill Who will be on the Family Team(FT)?Who from the family will watch, monitor and track the emotional and sleep/energy symptoms of the concssion and how will the Family Team commnicate with the School and Teams? be on the School Team (ST-P)? Who at the school will watch, monitor and track the physical symptomsof the concssion? Who is the ST-P PointPerson? Who will be on the School Team Academic (ST-A)? Who at the school will watch, monitor and track the academic andemotional effects of the concssion? Who is the ST-A PointPerson? Whowill beon the Team(MT)? How will the MT get information from all of the other teams and who with the MT will be responsible for coordinating data and pdates from the other teams? FAMILY TEAM SCHOOL PHYSICAL TEAM SCHOOL ACADEMIC TEAM MEDICAL TEAM Lessons learned from Jake REMOVE/REDUCE REMOVE from all physical activities! No organized sports No recreational play No PE, dance class No physical play at recess REDUCE home stimlation! Limit texting Limit TV Limit compter screens Limit video games REDUCE school demands! Mental Fatige Slowed Processing Speed Difficlty converting memory into New Learning 2

3 STEP 2: Edcate REAP: Adjst/Accommodate Accordingly Family Team: Ct back on electronics/stimlation at home begin to add back in Week 1 2 3?4 School Academic Team: Ct back on cognitive demands at school begin to add back in Test ot recovery in these 2 safe ways first. e PACE FAMILY TEAM Is the stdent/athlete 100% back to pre-concssionfnctioning? SCHOOL ACADEMIC TEAM Is the stdent/athlete 100% back to pre-concssion academic fnctioning STEP FOUR: PACE WHEN ALL FOUR TEAMS AGREE that the stdent/athlete is 100% recovered, the MEDICAL TEAM can then approve the starting of the Gradated RTP steps. The introdction of physical activity (in the steps otlined in order below) is the last test of the brain cells to make sre they are healed and that they do not flare symptoms. This is the final and formal step toward clearance and the safest way to gard against a more serios injry. MEDICAL TEAM approves the start of the RTP steps SCHOOL PHYSICAL TEAM Often the ATC at the school takes the athlete throgh the RTP steps. If there is no ATC available, the MEDICAL TEAM shold teach the FAMILY TEAM to administer and spervise the RTP steps. A Gradated Retrn-to-Play (RTP) Recommended by The 2012 Zrich Consenss Statement on Concssion in Sport* STAGE ACTIVITY FUNCTIONAL EXERCISE AT EACH STAGE OF REHABILITATION OBJECTIVE OF STAGE Symptom limited physicial and cognitive rest. No activity When 100% symptom free for 24 ho rs proceed to Stage 2. (Recommend longer symptom-free periods at each stage for yonge Walking, swimming or stationary cycling keeping intensity <70% maximm permitted Light aerobic exercise heart rate. No resistance training. If symptoms re-emerge with this level of exertion, then retrn to the previos stage. If the stdent remains symptom free for 24 hors after this level of exertion, then proceed to the next stage. Skating drills in ice hockey, rnning drills in soccer. No head-impact activities. Sport-specific exercise If symptoms re-emerge with this level of exertion then retrn to the previos stage. If the stdent remains symptom free for 24 hors after this level of exertion then proceed to the next stage. Progression to more complex training drills, e.g., passing drills in footballand ice hockey Non-contact training drills May start progressive resistance training. If symptoms re-emerge with this level of exertion then retrn to the previos stage. If the stdent remains symptom free for 24 hors after this level of exertion then proceed to the next stage. Following medical clearance, participate in normal training activities. Fll-contact practice If symptoms re-emerge with this level of exertion then retrn to the previos stage. If the stdent remains symptom free for 24 hors after this level of exertion then proceed to the next stage. Recovery r stdent/athletes) Increase heart rate Add movement Exercise, coordination and cognitive load Restore confidence and assess fnctional skills by coaching staff Retrn to play Normal game play. No restrictions *bjsm.bmj.com/content/47/5/250.fll 6 3

4 Commnication and Collaboration Commnity-responsibility Let REAP be yor roadmap Family 4

Family Each discipline is niqe and specialized while simltaneosly being completely integrated and reliant pon each other s inpt and data Consenss Statement on Concssion in sports 5 th international

5 Family Each discipline is niqe and specialized while simltaneosly being completely integrated and reliant pon each other s inpt and data Consenss Statement on Concssion in sports 5 th international conference held in Berlin, October 2016: Remove prevent SIS Rest Insfficient evidence prescribing complete rest After a brief period of rest dring the acte phase (24 48 hors) after injry, patients can be encoraged to become gradally and progressively more active while staying below their cognitive and physical symptomexacerbation thresholds (i.e. activity level shold not bring on or worsen symptoms Therapy Psychological Rehabilitation most individals get better in 10 to 14 days (children = 28 days) bt treatments for persistent impairments now inclde: psychological, cervical and vestiblar rehabilitation. In addition, closely monitored active rehabilitation programmes involving controlled sb-symptom-threshold, sbmaximal exercise have been shown to be safe and may be of benefit in facilitating recovery. Acollaborative approach to treatment inclding controlled cognitive stress, pharmacological treatment, and school accommodations may be beneficial. 5

6 Therapy Psychological Refer persistent symptoms reflect failre of normal clinical recovery = >10-14 days in adlts and >4 weeks in children. Treatment shold be individalised and target-specific medical, physical and psychosocial factors: An individalised symptom-limited aerobic exercise programme in patients with persistent post-concssive symptoms associated with atonomic instability or physical deconditioning, and A targeted physical therapy programme in patients with cervical spine or vestiblar dysfnction, and A collaborative approach incldingcognitive behavioral therapy to deal with any persistent mood or behavioral isses. There is limited evidence to spport the se of pharmacotherapy. If pharmacotherapy is sed, then an important consideration in retrn to sport is that concssed athletes shold not only be free from concssion-related symptoms, bt also shold not be taking any pharmacological agents/medications that may mask or modify the symptoms of SRC. Therapy Psychological Steadily accmlating literatre that a sizable minority of yoth, high-school and collegiate athletes take mch longer than 10 days to clinically recover and retrn to sport. Factors? Vestiblar isses Oclomotor isses Convergence insfficiency Cervical Strain Atonomic Instability Therapy there is a growing body of literatre indicating that psychological factors play a significant role in symptom recovery and contribte to risk of persistent symptoms in some cases. School Avoidance Secondary Gain Anxiety/Depression Consenss Statement on Concssion in sports 5 th international conference held in Berlin, October 2016: Family GetSchooledOnConcssions.com Website FOR edcators, BY edcators Edcators Empowering Edcators Failre to reach normal clinical recovery for children now is >4 weeks which means that typical recovery now is seen as day 1 p to 4 weeks. What do schools do with compromised learning for p to 4 weeks? Gradated Retrn to School Strategy in Berlin Gidelines Retrn to School (RTS) seat in chair Family Rsh to legislate Retrn to Learn (RTL) Edcation and empowerment of general edcation teachers to spport manifestations of concssion for p to 4 weeks: Mental fatige Slowed Processing Speed Difficlty with New Learning and Memory 6

Academic Adjstments for Mental Fatige Shortened day if needed bt only for a limited time Adapted from GetSchooledOn Concssions.

headaches atbay Snglasses or earphones to redce stimli Oclomotor concerns: Eye strain, especially with compter screens Print notes Large

in hallways Preferential seating Dysatonomia Concerns: Extreme fatige Postral Faintness/dizziness Emotional reactions (especially in yonger

Go for qality, not qantity Go for comprehension, not memorization Redce in-class and homework load Redcing # of problems Aditing lectre

GetSchooledOn Concssions.com Biggest If it is essential, consider: Mistake! Extra time on projects and tests Adjst (some, not all) de dates.

Prioritize crrent learning instead of make-p work Academic Adjstments for DiThclty Learning New Material Be thoghwl abot yor teaching.

Is material essential for end of level, next level and grading?

7 Academic Adjstments for Mental Fatige Shortened day if needed bt only for a limited time Adapted from GetSchooledOn Concssions.com Eyes closed/head down 5 to 10mintes per hor in classroom 15 to 20 minte strategic rest breaks in clinic Rest breaks: Usally to keep headaches atbay Snglasses or earphones to redce stimli Oclomotor concerns: Eye strain, especially with compter screens Print notes Large print Adio books Colored lenses/corrective lenses Vestiblar concerns: Notes to boards Print notes/teacher otlines/bddy notes Qiet passing in hallways Preferential seating Dysatonomia Concerns: Extreme fatige Postral Faintness/dizziness Emotional reactions (especially in yonger stdents) are often signs of mental fatige Academic Adjstments for Slowed Processing Speed Ct back on the amont of work. Go for qality, not qantity Go for comprehension, not memorization Redce in-class and homework load Redcing # of problems Aditing lectre material Oral vs written otpt Focs on mastery of material not work otpt Eliminate NON-essential in-class and homework load Adapted from GetSchooledOn Concssions.com Biggest If it is essential, consider: Mistake! Extra time on projects and tests Adjst (some, not all) de dates. Do not carry over work if possible It is NOT possible to keep p on or make-p all missed work! Prioritize crrent learning instead of make-p work Academic Adjstments for DiThclty Learning New Material Be thoghwl abot yor teaching. What is most important for the stdent to know at this time? Testing: mastery and grades Was material learned? ly and cognitively present? Is material essential for end of level, next level and grading? If not, eliminate If yes, re-teach, then assess mastery does it have to be a test? If a final is a mst, no more than 1 final per day, with 1 day of rest between finals No carry over make-p work or tests over school vacations; we need that time for cognitive rest and healing Adapted from GetSchooledOn Concssions.com 7

8 Family and Stdent? Rehab Model Atonimic Instability Flids/Salt Cardiologist Biofeedback Neropsych testing School spports School Team/ Academic AND School Team/ Psychologist Spervised Sbsymptom Exercise Family and Stdent Edcation Trst and By-in Psychiatrist therapist/ Nerologist Manal PT Vestiblar Therapist Nerooptometrist / ophthalmologist Neroimaging Center for Concssion BIAIA Dept. of Pblic Health Dept. of Edcation Dept. of Edcation RTL Initiatives Empowering Edcators Family and Stdent School Psychologist ED doctor Clinical Psychologist Clinic-based Vestiblar Therapists Clinic-basedATC BIAIA spporting CME trainings State medical/ healthcare provider trainings PT s getting extra vestiblar training State HS athletics/ activities trainings 8

9 30% of stdents with Protracted Recovery What s yor best gess? Oclomotor Vestiblar Dysatonomia Convergence Insfficiency Headache Cervical Adapted from GetSchooledOn Concssions.com Concssion Originated Concssion Exacerbated Headache LD ADHD Depression Anxiety Atonomic Instability Stdent: Anxiety Depression SchoolAvoidance Social isses Bllying/Safety Secondary gain Misattribtion of Symptoms Stdent &/or Parent Parent: Parent anxiety Can t bear the stdent strggling Parent need Secondary gain Family Team Team REAP For essential components: School Team School Team Academic It Takes a Village! It s not hard bt it s very complicated! Karen McAvoy, PsyD Karen.McAvoy@HealthONEcares.com

Director of Athletics

3341-8-1 Concussion Management Policy. Applicability Intercollegiate Athletics Responsible Unit Policy Administrator Intercollegiate Athletics/Director of Athletics Director of Athletics (A) Policy Purpose