Return to school after Concussion: Update on what you can expect in 2018


cropped-cropped-header521.jpgWestborough, MA March 28, 2018 It is time to update the current standard of practice for students who are out of school because of concussion.  “People are getting the message about the need to rest after sustaining a serious concussion” according to Michael Sefton, Ph.D., Director of Neuropsychology and Concussion Management at Whittier Rehabilitation Hospital in Massachusetts.  This post was originally published in 2014.  Still I am getting push back from parents and coaches about the length of time players must sit out before returning to play.  At the same time student athletes need to keep focused on getting back into the classroom.  They are also learning that students should not practice or appear in games until being symptom free for 7 days and have been cleared by their physician as required by MIAA.  Slowly, the message is getting out.
Some high school athletes are high energy students as well as elite athletes.  Some parents are not aware but it is true that when concussion sidelines and athlete he or she is highly vulnerable for school-related changes as well.  Schools or educational teams who are interested in offering a comprehensive concussion education program are encouraged to contact CAMP or Dr. Sefton directly for consultation.  By the time I see students they are often one to two months post-injury.
What I keep encountering is that students are struggling to maintain their academic focus after injury.  
“Whether or not a student receives support on an education plan has no bearing on the kind of support they might need when they return to school after a concussion” according to Sefton in a concussion program in June, 2014. There is a subset of athletes for whom the pursuit of their academic studies comes second to none. This level of intensity may be difficult to manage and may actually prolong the recovery from concussion.  For high intensity students a key to recovery is getting them to buy into the need to “shut down” for 7-10 days in the aftermath of their injury.  How is that possible?
COGNITIVE AND PHYSICAL EXERTION
The primary issue after a student sustains a concussion is decreased mental and cognitive energy and efficiency.  The metabolic activity in the brain is changed during post-injury time while the brain returns to its normal homeostasis.  This takes one to two weeks to resume the normal cascade of cerebral perfusion and neurotransmission.  It is now understood that a slow return to non-contact exertion may be initiated as long as physical symptoms are minimized.  
The key to recovery is rest – cognitive as well as physical rest for the initial 2 weeks following a concussion.  That means that if a student is out of sports because of a head injury or concussion he or she should not be studying 3 or more hours a day for mid-term exams or SAT preparation. A student should not work his regular hours at the supermarket or attend the upcoming rock concert.  Some students (and their parents) have a tough time hearing this recommendation and want to negotiate over the time spent at school and finding a balance of social activity.
Every year I get calls from frantic students and their parents about whether they can take the SAT exam in the same week they sustained a concussion.  More than once I received an urgent telephone call wanting clearance for a student to play in a soccer match in Portugal the following week without having first completed the return to play protocol.  They should not be permitted to sit for the SAT test and must not play in an international soccer tournament.  If they do, they can expect a significantly different score than they might otherwise have attained having not been concussed and place themselves at risk for second impact syndrome.
 SCHOOL NURSES AT FRONT LINE FOR STUDENT RE-ENTRY
It is important that parents notify the school nurse once a student returns to school after concussion injury.  The school nurse is a key person for making a successful return to school.  That may be intuitive if the student is using crutches or needs someone to carry his backpack.  But concussion is often considered an invisible injury and some prefer not to say anything to nurses.  I can tell you that school nurses are awesome to work with and I would not hesitate to use them for support.  Most nurses I work with are well-informed about concussion and the need for rest.  They allow students to check-in when they need to decompress from the travails of class work sometimes permitting a 20 minute power nap when needed.  Yes, inform the nurse when your son or daughter gets injured.
Rest is invariably the key ingredient to healing.  But in many cases students need not be kept home for days upon days.  Controlled return to school protocols have been reported on these pages and elsewhere (CDC) I recommend a partial day immediately following the injury with gradually longer times in class.  Try not to miss the same class every day e.g. math or science because these require ongoing repetition and build from one topic to the next.  However, parents and school counselors can  be quite creative about the return to school schedule until the student athlete is fully healed.
MIDTERM EXAMS AND SAT TESTING 
Students are expected to take standardized tests during their time in class.  Bigger tests like the SAT’s evoke bigger stress for athletes recovering from concussion.  Whenever possible school administrators have allowed athletes to make up routine tests when they are ready.  The law requires that schools accommodate students with medical needs – including concussion.  Most teachers are willing to modify an exam schedule for someone in need.  Modifications for the SAT require medical review and take months to get cleared by the College Board.  As a result, deferring the test until some later date is prudent especially if the injured student is a high energy, high demand student.
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One thought on “Return to school after Concussion: Update on what you can expect in 2018

  1. I have a student who was recently cleared to return to school who is still having significant headaches. This is an indicator that the student is not ready for the demands of school. Certainly students who are symptomatic must be given time for rest between classes and return on a limited basis until well.

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