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Concussion. Chris Coulson , D.O. TLC Family Care, Union IVHS Team Physician. Concussion Facts. Each year in ED 173,265 sports and recreation TBI diagnosed from birth-19 yo . Over 1 million visits annually in ED for TBI Increase by 60% last decade

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Chris Coulson, D.O.

TLC Family Care, Union

IVHS Team Physician

concussion facts
Concussion Facts
  • Each year in ED 173,265 sports and recreation TBI diagnosed from birth-19 yo.
  • Over 1 million visits annually in ED for TBI
  • Increase by 60% last decade
  • Bicycling, football, playground activities, basketball, soccer
  • Do you need to be knocked out to have a concussion?
  • If recognized and treated properly most children recover fully from a concussion
  • Multiple concussions tend to take longer to recover each time
    • Prolonged post-concussion symptoms
    • Increased cognitive impairment
definition of concussion
Definition of concussion
  • Disturbance in brain function caused by direct or indirect force to head.
  • Mild traumatic brain injury
  • No universal definition
  • Functional rather than structural injury
    • Results from shear stress to brain tissue
    • Caused by rotational or angular forces
    • Direct impact to head not required
  • HA most common symptom
  • Shear forces disrupt neuronal membranes
  • Allows K+ efflux into extracellular space
  • Resultant increase calcium and excitatory AA
    • Causes more K+ efflux
  • Leads to suppresion of neuron activity
  • Na+/K+ pumps try to restore balance
    • Increased energy requirment
    • But paradoxical decrease in cerebral blood flow
  • Disruptions of autonomic regulation can persist for weeks
    • Vulnerable to additional injury
second impact syndrome
Second Impact Syndrome
  • Child sustains a second trauma to head
  • Not recovered from a previous concussion
  • Can lead to deadly cascade of events that causes rapid brain swelling
second impact syndrome1
Second impact syndrome
  • A second blow to the head, even a minor one, can result in a loss of autoregulation of the brain's blood supply; this leads to a vascular engorgement and subsequent herniation of the brain that is usually fatal.3
Left without injury

Right with head injury

Red indicates electrical activity in response to task

concussion classification
Concussion Classification
  • No consensus regarding classification of concussion
  • Cantu, Colorado Medical Society, American Academy of Neurology
    • Based on concussion grade 1-3
    • Focused on LOC and amnesia
      • Research has shown these markers do not accurately reflect concussion severity or recovery
  • Ideally determine severity time of injury, provide prognostic info, guide RTP.
    • Does not exist
  • So, individual approach
    • Monitor symptoms to resolution
    • Graded RTP strategy
  • Who can return a player to practice?
  • Only an MD, DO, or LAT
    • Not a chiropractor
    • Authorization in writing to administration of the school
ohsaa 6 step protocol rtp
OHSAA-6 step protocol RTP
  • No exertional activity until asymptomatic
  • When athlete appears clear, begin low impact activity such as walking, stationary bike, etc
  • Aerobic activity to specific sport, strength training
  • Non-contact skill drills, dribbling etc
  • Full contact in practice setting
  • Game play competition
  • Athlete must remain asymptomatic to progress to the next level
  • Any symptoms, athlete returns to previous level and need reevaluated by health care professional.
  • Medical check should occur before contact
    • Final written clearance from the medical professional shall be obtained before the athlete engages in any unrestricted or full contact activity.
neuropsychological testing
Neuropsychological testing
  • Most beneficial when baseline measurements available for comparison.
  • Computer based
    • ImPACT
    • CogSport
    • Others
  • Written
    • Labor intensive
    • Several different ones
  • Cornerstone of evaluation, but no evidence it affects outcomes
sideline assessment tools
Sideline assessment tools
  • SAC
    • Standardized Assessment of Concussion
    • Single, simple tool
    • Assesses a variety of domains in the initial concussion assessment
    • Immediately after injury: memory, orientation, concentration, delayed recall
  • SCAT 2
    • Sport Concussion Assessment Tool 2
    • Multiple assessment tools
    • BESS (balance error testing, SAC, Glasgow Coma Scale, Maddock’s questions
does protective gear prevent concussion
Does protective gear prevent concussion?
  • No evidence that protective gear prevents concussion
  • Helmets and mouth guards reduce risk of skull and dental fractures
    • Not the incidence of concussion
  • Rule changes to eliminate dangerous behaviors
    • More of a protective effect
zackery lystedt law
ZackeryLystedt Law
  • 2009 enacted by Washington State
  • Requires concussion education for coaches, athletes, parents
  • Mandates removal if any sign of concussion
  • Need cleared by licensed health care professional
educator s guide
Educator’s guide
  • I am an educator. Why should concussions matter to me?
  • If you received a note from a physician stating a student in your class had a concussion and needed academic accommodations, would you know how to change student’s coursework?
    • Not only to continue participating in class
      • But to help him/her recover
educator s guide1
Educator’s guide
  • Would you be able to explain to a parent what changes you have made and why?
educator s guide2
Educator’s guide
  • Concussion is a serious brain injury
  • Significantly affect ability of brain to function at normal capacity
  • Key to recovery=physical and mental rest
  • Gradual progression back to activity
    • Athletics
    • Classroom
educator s guide3
Educator’s guide
  • Most concussions resolve days-weeks
  • Think of it no different than a student who missed a few days due to a minor illness.
  • However, some symptoms linger
    • Potential for long-term academic and social difficulties
educator s guide4
Educator’s guide
  • Proper management of a concussed student in the classroom by his/her educators is vital.
    • It allows student to continue to make academic progress through accommodations
    • It also prevents damage to the student’s academic record.
common concussion symptoms
Common concussion symptoms
  • Physical
  • Cognitive
  • Emotional
  • Sleep
physical symptoms
Physical symptoms
  • Headache
  • Dizziness
  • Balance Problems
  • Nausea/Vomiting
  • Fatigue
  • Sensitivity to light
  • Sensitivity to noise
  • Feeling mentally foggy
  • Feeling slowed down
  • Difficulty concentrating
  • Difficulty focusing
  • Irritability
  • Sadness
  • Nervousness
  • More emotional than usual
  • Trouble falling asleep
  • Sleeping more than usual
  • Sleeping less than usual
concussion symptoms
Concussion symptoms
  • These symptoms have a significant impact on classroom learning and schoolwork
  • Physical symptoms interfere with ability to focus and concentrate
  • Cognitive symptoms impact ability to learn, memorize and process information
    • Trouble keeping track assignments and tests
concussion symptoms1
Concussion symptoms
  • Struggles with school work
    • Worsen frustration, irritability, nervousness
    • originally caused by changes in brain chemistry
concussion symptoms2
Concussion symptoms
  • Disturbance in sleep patterns
    • Result in fatigue
    • Drowsiness during day
    • Compounds all the other problems
concussion management
Concussion Management
  • No two concussion are the same
  • Developing brains are highly variable
    • Each student has unique symptoms and recovery time
  • Notes from physicians will be variable
    • Some will have detailed instructions for accomad.
    • Some will just state the student has a concussion
  • Educators need to help determine needs for academic assistance and what form.
concussion management1
Concussion management
  • Physician may recommend absence from school or half-day work
    • Academic work demands focus, memory, concentration
    • Decreasing amount of activity in brain through absence of school and school work will help decrease symptoms
      • Healing process will begin
concussion management2
Concussion management
  • AVOID:
    • Extensive computer use
    • Texting
    • Video games
    • Television
    • Loud music
    • Music through headphones
  • Why?
    • These activities make the brain work harder to process information
    • Exacerbate symptoms, slow recovery process
concussion management3
Concussion management
  • No participation in any physical activity until cleared by a physician
    • No gym
    • No weigtlifting
    • No sports
  • Why?
    • Physical activity after concussion magnifies existing symptoms
    • SIS risk
concussion management4
Concussion management
  • The key to a speedy recovery
    • Physical rest
    • Mental rest
concussion management5
Concussion management
  • Every concussion is different.
  • Some students may need to miss school to help heal
  • Others will be able to continue their work with some accommodations.
5 phase of full return to school
5 phase of full return to school
  • Purpose of each phase is to identify what student can do without increasing symptoms
  • Also to avoid “triggers” that do worsen symptoms
  • Triggers“:
    • Reading
    • Computer use for classwork
    • Prolonged concentration
phase 1 no school
Phase 1: No school
  • High level of symptoms
  • Physical symptoms most prominent
    • Interfere with basic tasks
  • Treatment:
    • Rest brain and body
  • Interventions:
    • No school
    • No physical activity (sports, gym, weights, etc)
    • No activities that exac symptoms: tv, video games, computer use, texting
phase 2 half day attendance with accomadations
Phase 2: Half day attendance with accomadations
  • Students symptoms decreased to manegable levels
  • Symptoms exac. by certain mental activities that are complex, difficult, and long duration
  • Treatment:
    • Balance rest with gradual reintroduction to school
    • Avoid tasks that worsen symptoms
    • Avoid triggers
phase 2
Phase 2
  • Part day school
    • Focus core subjects
    • Prioritize what classes and how often
  • Symptoms reported by student addressed with specific accommodations
  • Eliminate busy work on items not essential to learning priority material
  • Emphasis on in school learning
    • Rest out of school, homework reduced or none
  • No physical activity
phase 3 full day attendance with accomadations
Phase 3: Full day attendance with accomadations
  • Symptoms have decreased in number and severity
    • Symptoms exac. by certain activities
      • Short time spans with known symptom triggers no drastic effects on symptom level
  • Treatment:
    • Student improves gradually increase demands on brain
    • Increase amount work, length of time spent on work, type of difficulty.
    • Gradually introduce known symptom triggers for short periods.
phase 3
Phase 3
  • Interventions:
    • Continue to prioritize assignments, tests, and projects
      • One test per day
    • Prioritize in-class learning material
      • Minimize workload
    • Gradually increase amount homework
    • No physical activity
    • Reported symptoms addressed by specific accomad.
      • Accommodations reduced or eliminated as symptoms wane and resolve
phase 4 full day attendance without accomadations
Phase 4: Full-day attendance without accomadations
  • Student may not have any symptoms or may have mild symptoms that are intermittent
  • Treatment:
    • Accommodations removed when student can function fully without them
  • Interventions:
    • Construct a plan to finish completing missed academic work and keep stress levels low
    • No physical activity until released by a healthcare professional (physician or LAT)
phase 5 full school and extracurricular involvement
Phase 5: Full school and extracurricular involvement
  • No symptoms present
  • Treatment:
    • No accommodations are needed
  • Interventions:
    • Before returning to gym, weights, sports
      • Complete gradual return-to-play progression
how do i figure out how much is too much for the student
How do I figure out how much is too much for the student?
  • Emphasis on return-to-school framework is allowing student to participate and learn without worsening symptoms.
    • If symptoms get worse=delay healing
  • Trial and error process
  • As student improves increase:
    • Amount of work
    • Length of time spent on work
    • The type or difficulty of work
    • ***Change only one of these at a time***
  • Gradually increase demands if symptoms do not worsen
  • If symptoms do worsen, stop activity for at least 20 min and let student rest
        • If symptoms relieved with rest, may re-attempt activity at or below the level that produced the syptoms
        • If symptoms not relieved with rest, stop for the day and reattempt when the symptoms have lessoned, most likely, the next day.
sympathy and understanding
Sympathy and understanding
  • Educators are used to hearing excuses for why classwork and homework in not finished.
  • Concussions are invisible injuries.
  • It takes time to heal
  • Student needs reassurance that they will not fail due to missed school days and homework
  • Need a consistent message from everyone
    • You understand what a concussion is
    • You understand what the student may be experiencing
  • Extend test times
  • Easily distracted
    • Small assignments
    • Breaks between tasks
    • Short concise instructions
    • Take test in separate quiet room
    • Move seat to front of room
    • Color code or highlight to emphasize important informaton
  • Sensitivity to light or sound
    • Dim lights
    • Move away from windows
    • Allow sunglasses or hat
    • Avoid assemblies
    • Eat lunch in quiet room
    • Avoid dances, pep rallies, etc
  • What if memory problems?
    • Provide class notes
    • Tape recorder for lectures
    • Use of fact sheets on tests to reduce demand on memory
    • Help student devise ways to memorize information
      • mneumonics
  • Trouble being on time or organizing skills?
    • Planners
    • To do lists
    • Have students repeat instructions in their own words to test comprehension of assignments
still struggling with these management techniques
Still struggling with these management techniques?
  • Consider one-on-one tutoring
  • Oral examinations
  • Use of note taker or scribe
  • Individual Education Plan (IEP) or 504 plan
    • For severe or prolonged symptoms
collaborative approach
Collaborative approach
  • Academic concussion management
    • Student’s physician, athletic trainer, guidance counselor, teachers, school psychologist, school nurse, and parents.
  • Duff, M.C. (2009). Management of sport-related concussion in children and adolescents. The ASHA Leader, July 14. Retrieved from
  • Centers for Disease Control and Prevention. Facts about concussion and brain injury. Retrieved from
  • SUNY Upstate Medical University. Concussion in the Classroom. Retrieved from
  • Centers for Disease Control and Prevention. Heads up to schools: Know your concussion ABCs: A fact sheet for teachers, counselors, and school professionals. Retrieved from
  • Centers for Disease Control and Prevention. Heads up to schools: Know your concussion ABCs: A fact sheet for school nurses. Retrieved from
  • McGrath, N. (2010). Supporting the student-athlete’s return to the classroom after a sport-related concussion. Journal of Athletic Training, 45(5):492-498.
  • Halstead, M.E., Walter, K.D., & the Council on Sports Medicine and Fitness. (2010). Sport-related concussion in children and adolescents. Pediatrics, 126:597-615.
  • Alfred I. DuPont Hospital for Children, & Delaware Health and Social Services Division of Public Health. Concussion in the classroom. Retrieved from
  • The Children’s Hospital. Information about concussion for school staff. Retrieved from