Implementing Medical Recommendations at School and Home

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1 Implementing Medical Recommendations at School and Home R E G I N A L A I N E, M S N, P N P - B C, C N R N R E B E C C A S T E V E N S, M S N, C P N P B O S T O N C H I L D R E N S H O S P I T A L N E U R O L O G Y D E P A R T M E N T A N D B R A I N I N J U R Y C E N T E R

2 Conflicts of interest We report no conflicts of interest

3 Objectives Review concussion management Typical recovery Rest and return to activity stages Discuss challenges to recovery How to identify and quickly intervene Ways to manage challenging cases Academic support Symptomatic management Case studies to support

4 Stages of Recovery Rest Gradual return to cognitive and physical activity Full clearance

5 Rest Most useful acutely following concussion, not as beneficial if started weeks after a concussion occurred. Physical and cognitive rest are the cornerstone in concussion management* Physical rest No sports, no gym class, extracurricular exercise including recess Cognitive rest Now a gold standard of post concussion treatment Recommended by the American Academy of Pediatrics, American Medical Society for Sports Medicine, The American College of Sport Medicine and the American Academy of Neurology. Brown and colleagues also demonstrated this in a recent study published in Pediatrics in Full days off of school, reduce or eliminate screen time at home, no homework or reading Do NOT to IMPACT testing Not useful in predicting point of recovery May induce symptoms or provoke anxiety Ref: 4th International Conference on Concussions in Sports in Zurich (2012)

6 Rest Challenges to rest Too little Prolonged symptoms Too much Prolonged bed rest is usually not shown to benefit recovery Review of literature assessing effectiveness of rest after a sport related concussion* Our experience is that it can cause anxiety, depression, trouble reaccommodating to a normal routine How much is the right amount? More clinical studies are needed to better determine this It is our general recommendation that full rest not be longer than 3-5 days Schneider et al., 2013, British Journal of Sports Medicine

7 Reintegration into school After a short period of rest, start return to school Shortened days initially half days most often Very little schoolwork initially No tests/quizzes **Do not tell the child to wait until they are asymptomatic to return to school without guidelines of an end point** Examples from practice Next steps Lengthen school day Make-up, keep up academic plan Extra time for school assignments Extra time for tests, limit the number in one day

8 Academic support Which classes to focus on Math, science, language usually builds one upon the other English, history and extracurricular units are usually independent and are easier to make up at a later date Allow breaks Work with the student and family to schedule short breaks throughout the day to help limit/decrease symptoms This will help keep them in school for longer days and not miss full classes

9 Academic support, cont d Guidance counselor and school nurse as an ally Someone to communicate and implement the recommendations Can help oversee the comprehensive workload Serve as a point person for parents to contact for questions and concerns Team meeting Can get all teachers on the same page Helps to ensure that accommodations and recommendations are being followed in all classes When 504 plan is useful Prolonged recovery If school is not responding to academic accommodation recommendations Most children recover before a 504 plan can be developed

10 National Association of School Nurses National Association of School Nurses (NASN) and concussion The school nurse is an essential member of a student s post concussion care team. It is a school nurse s job to provide concussion education to parents, student and schools staff members, help identify potential concussion, and assist the student in returning to academic and physical activities. NASN Position Statement 2013

11 Physical activity Full physical rest: no more than 2 weeks After 2 weeks full rest is not beneficial Currently a lack of consistent data regarding full rest Recent article in Pediatrics, Thomas and colleagues concluded that for adolescents strict rest following a concussion did not expedite recovery compared to 1-2 days full rest with a stepwise return to activity* Prolonged rest may lead to persistent symptoms Anxiety, depression Deconditioning may occur Gradually increase level of exertion and duration of exercise as tolerated at a non-contact level The patient/student should be symptom free or without an increase in symptoms in each stage for at least hour before progressing to the next stage. Thomas et al., 2015, Pediatrics

12 Physical Activity There are a total of 6 physical activity recovery stages. Stage 1: No activity Stage 2: Light activity- this can be started while patient is still symptomatic to help limit/prevent deconditioning but should Stage 3: not increase symptoms. Low exertion, non contact activities such as walking, swimming and stationary biking. Moderate exertion Sprints Resistance training Sports specific exercises like running drills or skating drills. Stage 4 non-contact training drills Stage 5 Full contact practice Consider neurocognitive testing (IMPACT) as indicated Children 13 and above Best with baseline testing Stage 6 Full contact games Final clearance

13 Why cognitive/physical rehabilitation is important Physical activity Full rest can lead to deconditioning which slows recovery Headaches, dizziness and from being inactive Patients that have been out of physical activity for a long period of time may benefit from physical therapy program for reconditioning Provides a motivated and structured environment Close monitoring of any physical symptoms Physical activity is useful for stress reduction Can decrease physical and emotional symptoms Cognitive/academics Staying out too long can be detrimental Deconditioning academically Stress from falling behind Away from peer group Children and adolescents naturally want to be social, by allowing prolonged rest at home it limits their peer socialization which than increased their risk for more emotional and depressive type of symptoms Studies show return to cognitive activity following short period of rest is not harmful

14 Challenges in rehabilitation Too little Patients may be hesitant to try Nervous about physical discomfort Anxiety about performance in school School and sport teams hesitant to allow return to sports Parents concerns Too much Patients not complying with physical rest activity recommendations Schools pushing too hard academically Pressure from teams/coaches/parents to return to sports Cost and access to therapies such as physical therapy and vestibular therapy Patient Example

15 Socialization Bullying Lack of physical indicator of injury Children recover at different paces Concussion from minor injury Attend school and look fine Peer- Friends and team makes thinking they are faking to get out of school work that they need to perform Adult- teachers and coaches may believe that if they are ok to be in school they are ok to participate in full activities and not allowing accommodations

16 Managing ongoing physical symptoms Prolonged recovery can be challenging Treat symptoms Often treating one symptom may help others Improved sleep may help cognitive difficulty and headaches Headaches Medications commonly used for primary headache disorders Alternative therapies such as acupuncture, chiropractic care and physical therapy Dizziness and balance issues physical or vestibular therapy if symptoms persist or are severe consider referral to otolaryngology Visual symptoms convergence insufficiency May need for visual exercises Concentration When indicated trial the use of stimulant medication Emotional symptoms Therapy/cognitive behavioral therapy Meds such as SSRI s Even with these interventions it is important for schools to acknowledge that there is still an ongoing medical concern and accommodations should remain in place Ongoing concussion may be the results of or cause other difficulty, most commonly schools stressors and anxiety

17 Concussion care at BCH Sport related injuries: Sports Medicine Other injuries or preexisting Neurological concerns: Neurology Neuropsychology Collaborative concussion clinic in Waltham Providers from optometry, ophthalmology, otolaryngology, sports medicine, neurology, physical therapy and sports psychology Criteria for the clinic includes patients that are less than 19 years of age with at least 2 of the following symptoms persisting for greater than 4 weeks from a diagnosed concussion. Dizziness (non-orthostatic), tinnitus or hearing changes Visual symptoms such as intermittent blurred/double vision, difficulty focusing on objects, headaches triggered by increased visual stimulation and visual accommodative difficulty. Balance difficulty Headaches Increased emotional struggles following the event Collaborative brain injury clinic Neurology, physiatry, neuropsychology

18 Questions

19 References Brown, N., et al. (2014). Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Pediatrics, 133(2). doi: /peds Giza, C., et al. (2013). Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology, Halstead, M., & Walter, K. (2010). Sport-Related Concussion in Children and Adolescents. Pediatrics, 126(3), Doi: /peds Harmon, K., et al. (2013). American Medical Society for Sports Medicine Position Statement. Clinical Journal of Sport Medicine, 23(1), doi: /jsm.0b013e31827f5f93 McCrory, P., et al. (2012). Consensus Statement On Concussion In Sport: The 4th International Conference On Concussion In Sport Held In Zurich, November British Journal of Sports Medicine, 47(3) doi /bjsports NASN Position Statement: Concussions--The Role of the School Nurse. (2013). NASN School Nurse, Schneider, K., et al. (2013). The effects of rest and treatment following sport-related concussion: A systematic review of the literature. British Journal of Sports Medicine, 47, doi: /bjsports Thomas, D., Apps, J., Hoffmann, R., McCrea, M., & Hammeke, T. (2014). Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics, 135(2). doi: /peds

Concussion Protocol. Signs and Symptoms. Pre-Concussion Management

Concussion Protocol. Signs and Symptoms. Pre-Concussion Management Concussion Protocol In recent years, we have seen an increase in concussions. A concussion is defined by The Children s Hospital of Philadelphia (CHOP) as a mild traumatic brain injury (mtbi) caused by