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WHAT IS A CONCUSSION?
First of all, you must understand and accept that all
concussions are serious. Do not be fooled by the term "mild
traumatic brain injury" or "temporary". The truth is that we
don't know enough about concussions to state categorically
that the injury is mild or temporary.
What we
do know is that a concussion is a brain injury that changes
the way the brain functions and hence produces changes to
the person who is injured. We are dealing mostly with
sport-related concussions at this time, but it doesn't
matter how the injury occurs, when you are told that one of
your students has a concussion it means that this injury
will affect the performance of that student in your
classroom. What you do to assist the student in the
classroom will have a profound impact on helping the student
recover from the concussion.
When a
student-athlete experiences the kind of force that results
in a concussion it means that the brain has bounced around
or twisted sufficiently to cause stretching and damage to
the brain cells, creating chemical changes inside the brain
and changing the communication network between the cells.
Since concussions affect people differently, we can never
say if an injured student will recover in a few days or a
few months, or longer. The reconfiguration and
reorganization of the brain cells may lead to changes that
can set off a series of symptoms that result in learning
problems, poor academic performance, and may also have a
profound affect on a wide range of cognitive, physical and
emotional areas.
The bottom line is that no
matter how a student receives a concussion, the classroom
teacher is critical in helping the student recover from the
injury and in making sure that the student is able to make
the necessary short- and long-term adjustments which will
ensure future success in learning and in life itself.
Please make sure you read the section on
The Brain
and view the training video at your earliest opportunity to
better understand what happens during a brain trauma that
results in a concussion.
RECOVERY PROCESS IN
ADOLESCENTS
If
there is one thing we are all learning from latest research into the
brain, it is that not knowing what you are doing when it comes to
concussion management can change who you are and who you could have
become. This is not turning out to be as temporary a dysfunction as
we previously were lead to believe. Many men and women in their 40's
and 50's are now discovering that the multiple concussions and
subconcussions they may have passed off as insignificant when they were younger are now showing up in symptoms
such as depression, anxiety, mood disorders, memory loss, early
onset dementia, suicidal thoughts, relationship problems, irritability,
and the
list goes on and on. Those persistent headaches that keep coming
back when you attempt a particular activity. The dizzy spells that
come now and then. The personality change you went through during
adolescence. All of these things may have something to do with brain
trauma you experienced over the years.
Furthermore,
with all of the attention being given to concussion management, we
are seeing evidence that after an athlete has been deemed to have
recovered from a concussion, he/she may not always return to the
same level of functioning in all areas of his/her life. For example,
once declared healthy following a rehabilitation program, many
professional athletes are never able to regain quite the same level of
performance they enjoyed prior to the original injury. Their
reaction time may have changed, ever so slightly, but just enough to
have an impact. They may not be quite as fearless as they once were,
or they may be more reckless, thus putting themselves at greater
risk of injury.
This leads us
to the conclusion that the injuries sustained by the brain when one
is concussed may not ever totally heal. In fact, during the
rehabilitation process it is possible that the synaptic architecture
within the brain is reconstructed and that this reconstruction may
not completely replace the original architecture. More will be said about this
later on in this section, but rehabilitation may in fact be better
thought of as the re-learning of skills. This re-learning may be
faster than when the skills were originally developed because not
all of the neural connections were lost or damaged as a result of
the concussion. There may be enough left so that the skills can be
brought back "close" to the pre-injury level, but just not
exactly the same.
SERIOUS
IMPLICATIONS FOR ADOLESCENTS
With
respect to adolescents (children from the age of 13 to 19) we now
must accept that a concussion is indeed a type of traumatic brain
injury that actually changes the way the brain functions. To add
further confusion to the mix, there are now two schools of thought
emerging on the impact of concussions on young brains.
First of all, research has found that teenagers who suffer sports-related brain trauma
have more widespread injury and prolonged brain swelling than
adults. This may be related to the fact that the developing
brain in a teenager has double the number of neural
connections than that of an adult, so an injury will impact a much
larger region of the brain. We also know that the immature
brain is approximately 60 times more sensitive to the chemical
substances that are produced following an injury. And since an
injury to the brain creates a massive power surge of
electrical energy that produces a cavalcade of chemicals
released into the brain in areas where the chemicals may not
normally be found, this increased sensitivity will have
serious consequences on a young adolescent brain.
Therefore,
many experts feel that high-school athletes might well be expected
to have a slower recovery than older adults and to be more
susceptible to severe neurological deficits should they be
re-injured during recovery. Because of the increased sensitivity to the
chemical changes following an injury, coupled with the
inadequate blood flow to help with the repair process,
complete physical and mental rest is absolutely critical to prevent further damage.
This is why we spend a great deal of time and energy
emphasizing the importance of all partners being completely
satisfied that all signs and symptoms have been resolved
before even beginning to return to physical activity.
On the other hand, some experts argue that teenage
student-athletes should have a greater potential for recovery
after a concussion because of their greater potential for
reorganization of the neural connections in the brain compared
with adults. The fact that the developing brain has double the
neural connections of an adult means that the excess connections
will allow for neural rerouting during the
recovery period.
It means that if the usual communication
pathway has been damaged or blocked because of a concussion,
the brain may be more easily able to find another route to
restore the communication to normal functionality. This leads
some experts to conclude that this functional plasticity may
in fact mean that teenage athletes never completely recover from their
original injury, but that they actually reacquire near normal
functionality because of the reorganization of the
communication network through new pathways that are closely
related to the original. In other words, the teenage brain discovers a new way of accomplishing approximately the
same results.
What is not completely understood is whether or
not the reorganization and rerouting can ever accomplish the
same results because of the widespread impact of the original
injury on so many other regions of the brain. Another
concern is that there may be areas of the brain that are not
reconstructed simply because they involve functions that may not be
commonly drawn upon by the student-athlete. This may explain changes
in behaviour or personality that occur following a brain injury. The
new behaviour is what is being reinforced and strengthened,
replacing the old behaviour. Therefore, when a coach is beginning to
rehabilitate an athlete through training that will resharpen the
skills of the player, he/she must also pay attention to the
motivation and rebuilding of attitude and passion to the game so
that both areas are brought back to pre-injury levels.
Therefore, the general consensus that teenagers take longer to
recover from brain injuries may simply be due to the fact that
teenagers who don’t allow sufficient time for the original
injury to heal may in fact never recover from their injury,
but rather they may develop new connections that may give them
almost the same functionality as they had pre-injury. This
means that it is even more critical that student-athletes take
more time to ensure that their concussion has had enough time
to heal so that they do not end up generating a rerouting or
reorganization that may be life-altering.
The reconfiguring that takes place in the brain during
a controlled rehabilitation period may be able to "recover"
most of the functionality that was impaired as a result of the
injury, but the affected areas of the brain may remain weaker
and vulnerable to future injury with less intense
trauma. Think of an athlete who receives a bad ankle sprain
for the first time. Even after the sprain has healed, the
athlete may find that he now has a "weak ankle" and is much
more easily injured, thus suffering the inconvenience of
future ankle sprains from less intense trauma to the ankle.
The same may be found for injuries to the brain. Once you get
your first concussion, you are much more vulnerable to getting
future concussions, possibly because you now have a weak area
of the brain that is more easily injured from less intense
trauma.
ADOLESCENT MAY BE OWN WORSE ENEMY
Unfortunately, adolescents may end up
inadvertently prolonging their recovery simply because of the
way the brain develops during this stage of life. For example,
teenagers are prone to taking risks and being impatient. Yet
when recovering from a concussion, patience is critical.
Frustration and anger may set in when an adolescent finds it
difficult to perform cognitive functions that were strong
before the injury. The lack of quick recovery will then create
a significant level of stress in the student-athlete. The
tendency is to accede to the pressure of the student-athlete
to return to play and therefore in many instances the player
is allowed to return to play perhaps too soon. Another
concussion will further acerbate the original injury and will
increase the level of stress and anxiety in the athlete.
Stress produces a chemical into the brain called cortisol that
increases concussion symptoms which may not present themselves
for days or weeks following the injury. The fact that these
symptoms keep coming up, especially if they are new symptoms,
causes the student-athlete to be increasingly frustrated,
angry or depressed, thus releasing more chemicals that prolong
recovery. Study
at University of Toronto Shows Non-Head Injuries May Reduce
Cognitive Functioning Researchers at the University of Toronto
released a report in November 2011 that has serious
implications for teachers who have student-athletes in their
classroom following a non-head injury. They may exhibit some
of the same cognitive deficiencies as student-athletes with
concussions, although the functional problems may not be
quite as severe. The study was done to discover the
effects that non-head (orthopedic) injuries, such as broken
legs or torn ligaments might have on the brain. They tested a
total of 72 varsity athletes, most of whom played football or
hockey. A total of 18 suffered concussions, 18 suffered
non-head injuries, and the remaining 36 did not suffer any
form of injury. All were given neuropsychological tests three
days after their injuries.
What they found
was that the concussed athletes showed slower reaction times
and worse results on memory tests than the players who had
muscle and ligament injuries. But what was interesting is that
the players who had muscle and ligament injuries performed
more poorly than uninjured athletes. The
researchers speculated that the athletes with non-head injuries may
have performed on the test at a level in between the concussed and the uninjured
athletes because of psychological factors which would include
emotional responses of frustration and anger about being unable to
perform and anxiety over how long it would take for their injury to
heal. It is
evident that an athlete with a concussion will perform more poorly
on the neuropsychological testing which is evidence that the cognitive
functioning level has deteriorated because of the brain trauma.
There may also be a relationship between the biochemical impact in
the brain that a non-brain trauma to another part of the body will
trigger since the neurons in the brain are connected to the sensory
neurons throughout the body. For example, a broken leg or a torn
ligament will generate a tremendous power surge to the brain
creating its own cavalcade of events including the release of
neurotransmitters and chemicals into the area of the brain receiving
the "painful messages" from the damaged area of the body.
This could result in a more contained damage to the brain, but the
interconnectivity of the neurons in the brain may still have some
effect on other functions, which in turn would lead to a
student-athlete doing more poorly on the tests than an uninjured
athlete. He/she will have "some" of the symptoms of
concussion that would have been caused in the exact same way if the
athlete was actually concussed. Another
possible conclusion from the U of T study is that no matter where an
injury occurs or whether it is an injury to the brain, muscles,
bones, etc., this trauma to the body has a direct effect on brain
functions and will result in a certain amount of deficiency. The
symptoms will present themselves in certain ways that may or may not
be noticeable or detectable. However, when an athlete suffers a
direct trauma to the brain, the intensity of the injury and the
amount of deficiency and disfunctioning is greatly magnified because
the brain trauma is much broader in scope and elicits a much greater
cavalcade of electrical and bio-chemical reactions. What
the University of Toronto study does confirm, in any event, is that
there is a need to pay attention to the emotional and mental health
of a student-athlete who is concussed in order to reduce the stress
levels and reduce the production of negative chemicals that will
delay recovery. Classroom teachers can play a huge role in this
area, as we will explore in more detail in the Guide for Teachers
found elsewhere on this site.
Personal Problems Can Affect Recovery Process
Family problems involving finances,
parental conflicts, work schedule or loss of employment by
parents, part-time job commitments, fear of losing your place
on the team, the feeling of hurting your team mates chances of
being successful, the loss of a potential scholarship,
appearing weak to the opposite sex or to your friends, the
loss of a source of self-esteem - these all wear heavily on
the mind of an injured student-athlete. This stress makes it
difficult for the brain to repair the damages neural
connections and adds to the chemical imbalance. The brain is
your most important, complex and vulnerable organ. When it
suffers an injury, it can affect your entire way of life.
Affects
of Sub-Concussions Make This a Truly Invisible Injury
A report published in the May 16, 2012 online issue of Neurology, the
medical journal of the American Academy of Neurology, has
indicated that there is now research that may be evidence of
the impact of sub-concussions on the level of cognitive
functioning of student-athletes. The
study included athletes in contact sports such as football
and hockey, non-contact sports such as track and nordic
skiing. The contact sport athletes wore special helmets that
recorded the acceleration speed and other data at the time
of head impact. It was found that contact sport athletes
experienced an average of 469 head impacts during the
season. However, athletes who were diagnosed with a
concussion were not included in the study. All
of the athletes took neurocognitive tests both before and
after the season. Something
of interest to teachers and parents is that when the
researchers tested the athletes on a measure of new learning
that occurred during the season, a higher percentage of the
contact sport athletes had lower scores than the non-contact
sport athletes. The data showed that 22% of the contact
sport athletes performed worse on the tests compared to 4%
of the non-contact sport athletes. Therefore,
the study suggests that there may now be evidence that
repetitive head impacts may have a negative impact on some
student-athletes, even if there is no diagnosis of a
concussion. This means that classroom teachers should be
aware of all of the student-athletes in their classroom and
should expect to see some signs of cognitive deficiencies
not only in students who have suffered a concussion, but
also in up to 20% or more of the other student-athletes who
do not get injured. Necessary accommodations should be made
for these students to get over their short term
difficulties. This
research confirms the belief that some student-athletes may
be more genetically sensitive to head impacts.
Teachers
and Guidance Counsellors Must Be Cognizant of All Conditions
Teachers and guidance counsellors must be cognizant of
these conditions when providing support to a student-athlete
who has suffered a concussion. It is vitally important for
the education professionals to reduce the stress levels in
the student while in rehabilitation.This means that the
accommodations suggested below must be considered and there
should be continuous guidance counselling to make sure that
the student is experiencing success and is not being
affected by negative emotions. Negative emotions stimulate
the cortisol chemical which interferes with the recovery
process and may lead to more anxiety and frustration.
COGNITIVE
DEFICIENCIES MAY BE PROLONGED
Research
is being done at the University of California, San Francisco
by
Dr. Mukherjee using advanced imaging techniques with patients
who have suffered a concussion. He is scanning their brain
right after the injury, a couple of weeks later, a month
later, then a year later and has found some interesting
results. For example, he has found some patients with bruises
on the brain which affect the cortex, or the gray matter,
which is consistent with the functional injuries that the
brain has undergone. He has also found small hemorrhages
within the white matter of the brain which indicate that there
has been some structural injury. He
has found evidence that early after an injury the areas of the
brain that are responsible for memory and attention are
different and less active from what one would find in a normal
person. But then he finds that six months to a year after the
injury, those very same areas may become more active and in
fact, hyperactive compared to a normal person.
This
has lead him to conclude that there are some definite changes
that occur in the brain after a concussion. He is continuing
with his research to see if he might be able to discover more
about the underlying science of how the brain works and what
really happens when the networks in the brain are disrupted by
a concussion.
While
the research being done by Dr. Mukherjee may not answer all of
our questions about concussions, it may shed some light on how
to treat student-athletes who suffer from prolonged
post-concussion symptoms. BEST
REHABILITATION THROUGH CONTROLLED STIMULATION
When it comes to post-concussion treatment
strategies, it has been widely accepted that there is no one
strategy or method that will work for all injuries. In fact,
we are finding that each injured student-athlete must be
treated individually, even though there are certain parameters
that seem to be a framework within which to operate.
The most popular treatment of concussion is simply to rest
the brain by ceasing all non-essential physical and cognitive
activities. This is still a wise course of action take
initially, but it is becoming apparent from some studies and
reports that student-athletes who still have symptoms after a
few days may be more at risk for prolonged recovery if they
remain at complete rest.
The carefully controlled and steady introduction of
everyday stimulation shortly after an injury seems to help the
brain rehabilitate as it rebuilds its ability to handle the
stimulation of a normal environment. The key here is to make
sure that there are adjustments put in place to help the
student-athlete gradually ease back into a normal routine. You
must not over-stimulate and risk the return of symptoms.
This is why we recommend light exercising such as walking
and a return to school with very specific accommodations for
the student-athlete. Over time the symptoms will resolve and
the brain will rebuild if you increase the stimulation
gradually and steadily without reactivating symptoms.
This is why classroom teachers can play such an important
role in the rehabilitation of student-athletes by carefully
monitoring the "return-to-learn" program within
the classroom.
The following suggesting will help you meet your
responsibilities to your students.
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GENERAL INTRODUCTION
First of all, in most cases a concussion may
not appear to have a significant impact on a student's
participation in class. You may get the feeling that the student has
no symptoms at all. However, you should still be monitoring the
student carefully during the first few days to see if there are some
difficulties that present themselves which are out of character. In
some cases, the student him or herself won't even be aware of the
symptoms, but you may observe some distinct signs that require
accommodations in the classroom.
You may also notice that with some students
the classroom activities that require concentration,
problem-solving, or learning new skills and concepts may actually
cause some symptoms to get worse or reappear as time goes on. The
student who seems to have recovered right from the beginning may
actually worsen during the first couple of weeks and then the
student will get frustrated and depressed which may lead to other
problems.
It is therefore wise to "assume" that a
student-athlete in your classroom who has suffered a
concussion will have some degree of difficulty with at least some of
the normal learning tasks. Some of those difficulties will be
expanded below and we will provide you with a bit of guidance that
may be of help as you work with your student.
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IMPACT OF
CONCUSSIONS ON A STUDENT-ATHLETE'S EXECUTIVE FUNCTIONS |
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| Whereas teachers spend more time with a
student-athlete than most other key adults, we felt that
it was important to spend a bit of time going over the
implications of a concussion on a student-athlete's
executive functions.
The frontal cortex of the brain, which is located in
the forehead area, has been accepted as the region of
the brain that is most involved in behaviour,
personality, and decision making. This is what we call
executive function, or a set of mental processes that
helps one connect past experiences to perform activities
such as organizing, planning, remembering details, and
managing your time and space. It allows one to
differentiate between good and bad, better and best,
same and different, consequences of actions,
goal-setting, predictions of outcomes and expectations
and perhaps most importantly for classroom teachers, the
ability to suppress socially unacceptable urges that
could lead to negative consequences.
The neurons in the frontal cortex extend throughout
all areas of the brain, so if one suffers a brain
trauma, it is quite likely that there will be areas of
the frontal cortex that will be affected. Even if the
actual damage is found in some other part of the brain,
the communication between those directly affected
functions and the frontal cortex will be disturbed.
While a student-athlete is going through the
rehabilitation process following a concussion, teachers
may find that the problems with executive function
acerbate the symptoms and result in all sorts of
behavioural and personality disorders. For example,
common everyday things might just be more difficult to
do. Working memory may be seriously affected and it
might be difficult for the student-athlete to do what
once came natural.
Normal Executive Function
It is important to remember that a student-athlete's
executive functions are still in the developmental
stage. This is the part of the brain that helps one
regulate behaviour and make sense of the world by
helping us to:
- Make short-term and long-term plans
- Keep track of time and complete assignments when
due
- Keep track of several different things at once -
multi-tasking
- Draw upon previous knowledge when talking to
someone or answering questions
- Evaluate ideas and think about the work we have
done
- Change our minds and make mid-course corrections
while thinking, reading, and writing
- Ask for help or seek more information when we need
it
- Engage in group discussions and projects
- Resist the urge to shout out answers in class or
interrupt
Signs of Executive Function Problems
A student-athlete who is recovering from a concussion
may have difficulty:
- Planning projects
- Determining how much time a project will take to
complete
- Communicating orally or in writing in an organized,
sequential manner
- Memorizing and retrieving information from memory
- Initiating activities or tasks, or generating
ideas independently
- Remembering information that is used in a
conversation, even while speaking
- Remembering the phone number or email address
while dialing or texting
Strategies that Classroom Teachers May Use to
Help
As a classroom Teacher, you will likely have many
strategies that you have found work well when trying to
develop executive functioning in your students, but the
following are examples of some of the strategies that
have achieved success:
General Strategies
- Take things one step at a time.
- Use visual aids and concrete materials whenever
possible.
- Use timers or electronic equipment with alarms to
help keep track of time.
- Display clear and specific schedules and review them several
times a day.
- Provide both written and oral directions and ask
the person to repeat them back to you.
- Allow for longer time to shift from one activity
to another.
Managing Time
- Create checklists and "to do" lists,
estimating how long tasks will take.
- Break long assignments into chunks and assign time
frames for completing each chunk.
- Use visual calendars at to keep track of long term
assignments, due dates, chores, and activities.
- Be sure to write the due date on top of each
assignment.
Managing Space and Materials
- Make sure that the student-athlete's desk or work
space is clean and organized
- Consider having separate work areas with complete
sets of supplies for different activities.
- Schedule a weekly time to clean and organize the
work space.
Direct Instruction Strategies
-
Select
a meaningful goal or skill the student will need to
learn and present it at the level of the student;
-
Provide
a simple rationale to help the student understand
the relevance of the skill;
-
Give
clearly stated task directions (limit the number of
steps) and ask the student to repeat or paraphrase
the directions to ensure understanding;
-
Break
tasks into small steps and demonstrate each step;
-
Provide
opportunities for student response and practice at
an appropriate pace;
-
Provide
immediate feedback and error correction when
necessary—feedback should be positive and
systematic; and
-
Use
verbal praise and encouragement frequently.
Precision Commands
-
Use
a direct statement telling the student to start
(rather than stop) a behavior;
-
Look
directly at the student as you give the request,
move close, and use a soft, calm voice.; speak
clearly, slowly and concisely—do not shout.
-
Limit
requests to only two or three at a time and give
requests that the student is capable of following;
-
Allow
enough time for the student to follow through; and
-
Recognize
their effort with verbal praise and encouragement.
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| EXPECT THE UNEXPECTED
Before we get into the specific accommodations below,
the first thing we would like to warn classroom teachers
about is to expect the unexpected. The effects of brain
injury are certainly unpredictable at best. The more
severe injuries will require long-term accommodations.
The "minor" injuries, and I caution that we
hesitate to use the word "minor" when
describing brain injuries, may seem to resolve within a
couple of weeks.
Nonetheless, a brain injury will have some impact on
a student-athlete's basic cognitive abilities such as
memory, learning, attention
and concentration,
word finding, and visual perception.
It may also have a negative impact on other skills
necessary for academic success, including reading,
arithmetic reasoning, vocabulary, writing, and spelling.
Pressure will come from parents, teachers and
student-athletes themselves who worry about the affect
on successfully passing the course requirements and
perhaps being forced to repeat grades or programs or not
being able to graduate on time or enter a university
program of choice.
Some students need to study much longer than usual
and find that they do worse than before. Others complain
about having to read things over several times and still
can't remember what they have read. You will hear
student-athletes complain about studying for tests and
then "freezing" when it comes time to write
the answers. One complaint that is common is that
writing simple essays or short stories takes forever to
get started. This is especially stressful when one is
forced to do the writing within a time constraint. It is
difficult for student-athletes suffering from a
concussion to pay attention to lectures for any length
of time before their mind begins to wander, despite
their efforts to remain focused. And they will be
totally exhausted at the end of the day, and unable to
find the energy to do any homework.
Therefore, when you discover that one of your
students has had a concussion, rest assured that he/she
is going to be affected in the classroom. The following
accommodations won't all be necessary all the time, but
it is nice to understand that there are strategies you
can incorporate in the classroom that may help with the
rehabilitation process. |
Cognitive difficulties:
- Trouble paying attention
- Difficulty remaining on task
- Slowed responses and or processing of information
- Difficulty shifting attention
from task to task
- Organization challenges
- Reduced academic performance
Social behavior
difficulties compared to pre-injury:
- Impulsive behaviors
- Initiation difficulties (trouble starting things)
- Changes in mood
- Depression
- Defiance
- Fatigue
- Confusion
Physical difficulties:
- Headaches
- Blurred vision
- Changes in taste or smell
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DO NOT SEND WORK HOME
Teachers are advised that until the student is brought back to
school it is not recommended that any work or notes be sent home in
order for the student to keep up. The parent/guardian has been
advised to keep his child from any reading or other activity that
will add to the cognitive stress levels. Homework that is sent to
the student may not get done anyway. The student-athlete will not
have the ability to focus or concentrate on the work, nor will
he/she be able to handle new skills or concepts through independent
study. The brain is just not capable of these kinds of functions
while it is dealing with the immediate repair of the damaged area of
the brain. This will cause stress in the student-athlete and will
further delay recovery. The parent/guardian has an obligation to make sure that their
child does not jeopardize the early rehabilitation by causing
further stress on the child's brain.
FIRST DAY BACK
The first day back should be a very light day for the
student-athlete. Teachers should spend some one-on-one time with the
student to assess the situation and reassure the student that he/she can
determine his/her own pace for returning to full participation. It would be a great idea
if you could also reassure the student-athlete that his/her school
year is not in jeopardy and that you will be working with him/her to
successfully complete the course, despite the injury.
This last point is far more important and critical than it
sounds. The human brain cannot discern between anxiety and fear and
it has been found that fear cuts off up to 1400 upper brain
functions such as logic, reasoning, planning, problem-solving,
control of emotions, etc. These are the executive functions of the
brain that are still not developed fully in an adolescent and are
the reason why the teen years are so volatile to begin with.
Therefore, anxiety from a lack of understanding of what is happening
to him/her as a result of the brain injury cuts off the frontal
cortex functions and actually releases chemicals into the brain that
are counter productive to the healing process that is taking place.
By providing reassurance that the support is going to be provided
and that no matter what happens the student-athlete will not need to
worry about successfully completing the course, you will be helping
stimulate helpful chemicals instead of damaging ones.
It is also advisable for the parent/guardian and the
student-athlete to meet with the School CMP Leader, the guidance counselor
and the classroom teachers to go over the procedures involved in the Student-Athlete
Concussion Management Program. We want everyone to be "on the
same page" in order to make sure that the rehabilitation goes
well on both the physical and cognitive sides of the equation. While
we realize that it may be difficult to arrange for this kind of
meeting, we would encourage everyone to maintain some communication
with each other so that you are all aware of the status of the
student-athlete. It is encouraged to invite the student-athlete to
feel free to communicate by email with classroom teachers at this
time in order to give the student-athlete a better sense of support.
Teachers and parents must also be aware that symptoms may worsen
during the first few days back at school. This might have an impact
on the emotional state of the student-athlete who just wants to get
better so that he/she can return to playing on the team. The harder
the student-athlete tries, the more stress is put on the brain to
concentrate on learning and engaging in academic activities. The
student-athlete must be constantly encouraged to share his/her
feelings of frustration and also to let everyone know if symptoms
are returning or getting worse.
CURRENT EMOTIONAL STATE
If at the time of the brain injury a student-athlete has a
history of concussions, is experiencing medical problems, or already
has a learning disability, it may take much longer to recover from
the concussion.
Another consideration is the amount of stress that the
student-athlete was and/or is experiencing in other areas of his
current or recent history. Family problems such as economic
hardships, tension between parents and adverse living conditions all
contribute to the mental health of a student-athlete. If a
student-athlete had problems in his/her life before the injury,
those conditions will still exist and could interfere with the
recovery process and make the brain more susceptible to further
damage.
From a neurological perspective, if the neurons are forced to
divert some of the little precious energy available to deal with
emotional stress caused by family problems, then it will have less
energy to devote to the recovery process. While the student-athlete
is at school it becomes imperative for all teachers to do everything
possible to minimize the stress and anxiety levels that may be
attributed to the "return to learn" process.
ATTENDANCE
Depending on the symptoms, a student-athlete may need to remain
home at complete rest for several days following the injury. Even
upon returning to school, the student may need to stay home every
second or third day as symptoms may return. Therefore, you must be
prepared for irregular attendance and you should not count on a
concussed student being present on any particular day or class. It
is possible that the student-athlete may plan on being present on a
certain day and then symptoms flare up the night before or the
morning of the class and be unable to attend.
It may also be necessary for the student to prioritize his/her
classes, attending core subject classes only, while resting during
electives. Therefore, depending on the subject, a classroom
teacher may not see the student for days on end, even though the
student is at school. The student-athlete knows that he/she must try
to focus the bulk of his/her energy on keeping up
with compulsory subjects, but may find it necessary to cut
back on some of his/her electives due to a lack of energy..
The student-athlete might also find it easier to attend school during
mornings or afternoons, depending on when symptoms are worse. For
example, a student who is having trouble sleeping may be too tired
in the morning to attend classes and will therefore find the
afternoons easier. On the other hand a student who finds that his
symptoms worsen as the day goes on may prefer to attend school in
the morning and go home in the afternoon.
The daily schedule is something that should be addressed by the
guidance counselor and the classroom teachers.
REST PERIODS DURING THE DAY
Following a concussion a student-athlete may find that he/she is
absolutely drained of mental energy. Some have likened it to a
battery that loses its charge much faster than before. Further
adding to the confusion, and to the internal stress felt by the
student is the fact that the mental energy level will vary from day
to day and activity to activity. In fact, despite everything that
the student-athlete is doing, he/she may still find that the symptoms are
getting worse. This is normal and the classroom teachers must be
sensitive to this phenomenon of concussions. In some cases the
symptoms may not even appear for days or weeks following the initial
injury. Teachers will have to be prepared to consol their
student-athletes who are going though this phenomenon and who may
begin to get depressed or anxious, wondering if they will ever
recover from the injury. This is a time to assure them that what is
happening is normal, but the Teacher should also make sure that the
parent/guardian is aware of the increasing frequency of new symptoms
so that further medical treatment may be sought.
Some student-athletes find that if they are allowed to take
periodic rest breaks of 20 or 30 minutes in a quiet place when
symptoms flare up, they are able to remain at the school for longer
periods of time. Therefore, you should work out a procedure whereby
the student-athlete could excuse him/herself and perhaps go and lie
down in the nurse's room or the staff lounge for a while. It may be
that all that is required is for the student-athlete to go to the
library to do seatwork if the noise level gets too loud in the
class. The rest breaks will gradually decrease in frequency as the recovery process
continues.
Some sort of procedure will have to be established with school
administration so that you can keep track of the whereabouts of the
student. You cannot simply allow him/her to disappear with no one
being aware of his/her location. This is not just to address
liability issues with respect to supervision responsibilities but also in case the
student has a health issue that may require emergency attention. You
must be aware of the whereabouts of the student-athlete at all
times. Therefore, you may want to have the student-athlete go
directly to the office area once he/she leaves your class. And then
check over the P.A. system to see that he/she arrived.
It may also be a good idea to send along a "buddy" when the
student needs one of these rest sessions so that the
"buddy" can do work nearby while the student is resting.
This should not be an opportunity for socializing. It is a time to
rest.
If you do employ the buddy system, make sure that the
"buddy" is permitted to get up and follow the
student-athlete out of the classroom at any time he/she decides to
leave. This will ensure that the student-athlete is always
accompanied by someone. We have come across many examples of a person appearing
to be perfectly normal one minute and then collapsing on the floor
the next. We want to have a buddy around if this ever happens to one
of our student-athletes.
ASSIGNMENTS
One of the common symptoms of concussion is the inability to plan
and organize. This means Student-athletes may be having trouble processing information, so
you should allow extra time to complete homework assignments.
They
may even lose track of homework assignments or have difficulty
simply approaching the planning of a project. This may appear to be a
completely different student than you had prior to the injury. It
will be extremely frustrating for the student and will also be a bit
frightening as he/she wonders if things will ever get back to
normal. As his/her teacher, you must continue to give the student
hope that things will eventually get better as long as he/she
follows the "program" and puts as little exertion on the
brain as possible.
You may find that the student comes to class without text books,
material or pens. Unfortunately, because of the demands on a
classroom teacher it is possible that these problems could go
undetected for some time. The student-athlete's "buddy"
can be a huge help in this respect. He/she can help him/her get organized and even meet at the locker
to make sure that all of the materials are brought to the class.
He/she can even share material and/or books when they are misplaced.
You
may also want to consider reducing the expectations or requirements
of the course so that the
student-athlete is not required to produce the same amount of work
as normal. This partial work load will assist in the recovery
process even though it may create some difficulties for the teacher
when it comes to evaluation of progress. Remember, this is not the
same student as before. The workload cannot be the same as the
others in the class. His/her brain is not functioning at full
capacity. Unless it is absolutely necessary, you may even consider
reducing the emphasis on spelling and grammatical requirements for
written work, concentrating on the ideas instead. It will be
difficult for the student-athlete to maintain his/her former
standards in these areas.
Once the student-athlete is able to do homework it is always
advisable that you provide him/her with written instructions that
can be followed while at home rather than expecting him/her to remember what
was said in class. Keep in mind that while in rehabilitation, the
student-athlete may not be able to recall instructions or may find
it stressful trying to remember exactly what the teacher said. By
having the instructions down in writing it will be easy to follow at
home. The "buddy" may also be able to help with this if
they are in contact by phone each evening.
TESTING
This is perhaps one of the most important areas of adjustment
that will have to be made for the recovering student-athlete,
especially if the injury happens during Grade 12 or while taking
courses that will affect entrance to university or college. And yet,
if a student-athlete is forced to take a test while he/she is
symptomatic it will place him/her at a great disadvantage for coming
up with passing grades. In addition, the mental effort required to
prepare for the test may even exacerbate the symptoms and delay
recovery. We know how stressful tests can be at the best of times,
so imagine what this kind of "electrical activity" would
do to a concussed brain.
If possible, it would be best to find an alternative evaluation
procedure that would be suitable for the student-athlete. This is
something that should be considered if the exam is not a mandatory
requirement, such as an entrance exam for post-secondary school. It
is quite reasonable to calculate the marks for a student-athlete
based on his/her daily seatwork, class participation and
assignments, or to just use the marks earned up until the time of
injury.
Postponing testing until the student-athlete is fully recovered
is another alternative, but the anxiety of knowing that one will be
facing a huge challenge to get caught up and do the test at a later
date may also have serious consequences to the recovery process.
Therefore, postponing the test is not recommended. Keep in mind that
concussion symptoms may return even after it seems as if the
student-athlete is symptom free. It would be terrible if a test
brought on a "repeat concussion", but that is precisely
what could happen if the brain is overstressed too soon after
recovering from the original injury.
One thing is for certain - you should never expect an injured
student-athlete to take part in a major mid-term or final exam
during the recovery period. If there is no other choice, then try to
schedule the exams so that the student-athlete can take only one per
day or every second day with plenty of study time in between. You
may even be able to break the exam up into smaller chunks and have
it completed over several days instead of all at once in one
sitting.
Some student-athletes may feel that they are well enough to take
tests, but even with these students teachers are cautioned to be
prepared to provide them with extra time to complete the test. The
reason for allowing this extra time is because when the brain is
impaired as a result of a concussion, it takes longer to
process information, so the student-athlete may be able to
successfully complete the test, but it will take longer for him/her
to process material.
If a student-athlete wishes to take a test, it might be advisable
to have him/her take the test in a smaller exam room where
there may be fewer distractions and pressure.
One suggestion that may help is the utilization of
multiple-choice or open-book tests which tend to minimize the need
to retrieve information. The student may be able to recognize the
correct answer, but may be unable to mentally recall what the answer
is. Those "connections" in the brain may be damaged.
Therefore, whenever possible, try to create this type of test for
the recovering student-athlete and you may be surprised with the
positive results compared to what you would get if you forced the
student-athlete to try to retrieve the information.
SENSITIVITY TO LIGHT, NOISE, CROWDS
Student-athletes who are suffering from concussion symptoms often
have difficulty during the recovery period from over sensitivity to
light or noise. If the fluorescent lighting in the classroom is
bothering the student, then perhaps you can make some accommodations
that won't interfere with the rest of the class. For example, you
might allow the student-athlete to wear a baseball cap or sunglasses
that will cut down on the light. You may even be able to turn down
the lights a bit in one part of the room.
As for noise, it may be advisable to allow the student-athlete to
eat lunch in a quiet area rather than in a noisy cafeteria. This
is another opportunity for the student-athlete to have a
"buddy" who will accompany him/her for lunch. Anything
that is going to reduce the chances of causing stress on the brain
is encouraged.
Be advised that even after recovering from the concussion, the
student-athlete may be permanently sensitive to light and/or noise.
This is not uncommon with some student-athletes. Most of the
symptoms will go away, but because we are dealing with the most
complex organ in the body, we just don't know what the end results
will bring. Some of the damage may be permanent and the
student-athlete will need to learn to cope.
Changing classes may be accomplished by allowing the
student-athlete to leave class early so as to avoid the noise of the
rest of the students moving in the hallway. Anyone who has been
caught in the hallway of a large high school during class change is
well aware of the noise as well as the physical contact that is
often made as people are rushing too and fro. Therefore, by allowing
the student-athlete some time to move prior to the heavy traffic,
you will be helping him/her prevent some further physical or mental
stress which may impact on the original injury.
LIMITED PHYSICAL ACTIVITY
During the recovery process the student-athlete should absolutely
not take part in any gym class. Nor should the student be around any
activity where there is a risk of him/her being accidentally struck
on the head by an errant basketball or baseball. Any blow to the
head or body could result in a repeat concussion which could have
serious consequences.
The student-athlete should also avoid carrying around heavy
backpacks and loads of books from class to class. This physical
exertion may be enough to bring on symptoms.
Even the climbing of stairs should be avoided, or at the very
least, the student-athlete should be allowed to move up and down
stairs when there is no danger of being bumped by other students.
It has been found that playing musical instruments may also be
too much exertion for a recovering student-athlete, so if the
student is in a band, it may be wise to avoid playing at least until
the major symptoms subside.
That being said, it is quite acceptable for the student-athlete
to attend gym class and simply "walk" around for periods
of time. This light aerobic exercise is good on the recovery
process. Once again, where the student-athlete does this walking is
important. He/she should not be at risk of being struck on the head
accidentally.
A bit of physical activity is permitted as long as it is light
and there is no resistance involved. Even riding a stationary bike
is fine, if no symptoms return, but with no résistance and just
lightly. This little bit of exercise can actually have a positive
affect on the mental stress level of the student-athlete and help
increase the blood flow and oxygen levels in the body. All of this
may help with the rehabilitation process, as long as the exercise
does not bring on symptoms.
READING
If a student-athlete finds reading to be too strenuous during the
recovery period, some teachers have arranged to have another student
"read" to the injured student, or create tapes that can be
listened to by the student. It is crucial that as little mental
exertion be created as possible in the initial stages of recovery.
This stimulation should be increased gradually under careful
observation. Reading is hard on the brain.
You should not ask the student-athlete to read orally in front of
the class. This may prove embarrassing because of the difficulty in
recognizing words because of his/her impaired reading skills.
The student-athlete will be able to build up to normal
reading functionality in time, so if you can give him/her opportunity to do a
bit of easy reading it will help the recovery. This will be
considered "mental conditioning" and is just as important
as physical conditioning. Just be prepared for
the student-athlete to tire quickly or lose focus on what is being
read. As always, if any symptoms return while reading, then the
student-athlete must cease that activity.
TAKING NOTES
It has often been stated that writing is one of the most
difficult skills for a person to master because of the different
parts of the brain that must work to coordinate the activity.
Therefore, during the recovery period it is advisable to have
another student take and provide photo copies of lecture notes for
the student-athlete. This will allow the student-athlete to
concentrate on listening to the teacher instead of both listening
and writing notes at the same time. This may not seem like a big
deal, but when your brain is dysfunctional, it can be huge.
Some teachers also allow student-athletes to tape essays, stories
and assignments. Therefore, they can say what they would normally
write.
If possible, provide the student-athlete with an outline of the
lecture so that it will be easier to follow the presentation and
keep on track.
CLASSROOM SEATING
Sitting at the front of the classroom or moving away from the
windows and doors is something that is recommended for
student-athletes recovering from concussion. This eliminates
unnecessary distractions. Many students ask to sit at the front of
the room while recovering so that they can concentrate better on
what the teacher is saying and avoid distractions from the rest of
the class.
By sitting near the front it is much easier to listen to what the
teacher is saying, so there won't be as much stress trying to hear
over any other background noises.
TUTORING ASSISTANCE
Some teachers are able to arrange for the services of a peer
tutor or classroom assistant who will work with the student-athlete
during the recovery process. This helps the student-athlete keep up
with the concepts taken in class, keep track of assignments, tests,
etc. For student-athletes who are forced to attend school every
second day or on a part-time basis, a home tutor can work wonders.
EMOTIONAL STRATEGIES
The student-athlete who is suffering from a concussion is very
confused and may have undergone damage to the brain that will result
in behavioural or emotional symptoms. Therefore, you may see
emotional outbursts or behaviour that is completely
out-of-character. This is normal during the rehabilitation period
and teachers must be sensitive to the problems. Do not take things personally
or overreact. Just make sure the rest of the class understands that
you are not allowing him/her to get away with anything that is unacceptable.
It is advised that you avoid placing the student-athlete in a
situation which might produce significant stress on the brain. For
example, if the student does not raise his hand, do not call on
him/her to answer a question or go to the front of the class to make
a presentation of some sort. This may cause an unhealthy level of
anxiety which could produce a "fight or flight" response
and you will then have another problem in your class.
You should also be aware of signs that the student is becoming
frustrated. This goes for times when he/she appears to be getting
overly excitable or stimulated. When this happens it is best to
allow the student to leave the class with a friend to go someplace
where he/she can rest for a few minutes to calm down.
The natural goal of the brain is to be calm, happy and
functioning. If the brain is experiencing these conditions then it
produces neurochemicals that counter act the negative cortesol that
causes stressful conditions and interfere with recovery. If the
student-athlete is experiencing negative emotions before the injury,
then the brain is already in a conflict situation and the damage
from physical and/or cognitive trauma will be worse. Happy thoughts
and success in the class will release the good "dopamine"
neurotransmitters and this will help with recovery. Therefore, the
accommodations described on this page are designed to help the
recovering student-athlete experience success and sense that his
condition is improving. If he senses that his conditions are
deteriorating, then this will cause more stress, release harmful
neurochemicals and his recovery will in fact be delayed.
AVOIDANCE
If a student-athlete is obviously having difficulties in one area
of the curriculum, try to direct him/her to focus on areas where
he/she will achieve success. It it better for recovery if the
student-athlete experiences a lot of positive feedback and success.
It is also important for the classroom teacher to acknowledge the
frustration and anger that the student-athlete is feeling. Removing
the student from areas which are going to trigger negative emotional
outbursts is something that should be considered.
RELATIONSHIPS
Because the student-athlete cannot take part in regular
activities while recovering, peer relations often take beating following a concussion injury.
Classroom teachers may be able to spot signs of changes that need to
be addressed. Friends may not fully understand what their "old
friend" is going through. They may take things personally when
actually the student-athlete is unaware of what he/she is doing. We
know that teenagers are creatures that feel they are falling deeply
in love with their soul mates during high school. If a
student-athlete's character changes in a negative way because of a
concussion, this may cause some relationships to be strained and the
student-athlete may feel his/her world is crumbling. Just be there
for the student-athlete and help him/her get through these trying
times.
It would also be a good idea to go over some of the symptoms of a
concussion with the entire class so that they become more aware of
what may be going on with their classmates who are suffering from
this type of injury. If you are teaching a Grade 11 or 12 class, you
can rest assured that anywhere from 30 to 50% of the students who
participate in contact sports have experienced at least one
concussion or sub-concussion during their lifetime. The information
would certainly be of use to them in the future.
A student-athlete with a concussion is likely to exhibit
impulsive behaviours that are hard to explain or rationalize. They
will be very moody and often will be defiant to people in authority,
lashing out when least expected. Keep in mind that this is not the
person you used to know. The brain injury has changed this person
and in time, with proper rehabilitation, the old person will return.
Everyone just needs to be patient and understanding.
COUNSELLING
A brain injury can often affect a student-athlete emotionally.
Therefore, it is advisable to arrange for the student-athlete to
meet periodically with a guidance counsellor or to meet with a
teacher after school or during the day. Sometimes the
student-athlete needs someone to confide in and just to talk with in
order to help get a grip on his emotions and his mental outlook.
The student-athlete
should be counseled on the importance of him/her being honest about
symptoms that occur as he/she is gradually increasing the day-to-day
workload in class. This is not to be considered an excuse to stay
out of work, nor should the student-athlete be trying to hide
symptoms. If a particular kind of assignment or activity brings on
symptoms such as headaches, confusion, concentration difficulties,
etc., then it is critical that the student-athlete let the teacher
know.
DEPRESSION vs UNHAPPINESS
We feel that we should take a full section here to deal with
depression. Depression is something that adolescents experience
often and in fact is one of the most common mental disorders of this
age group. When a student-athlete suffers a concussion it is even
more common for him/her to present signs of depression so classroom
teachers should be on the careful look out for the obvious signs.
Keep in mind that the main source of happiness for human beings, and in particular
adolescents, is social connectivity and a sense of purpose. A
student-athlete who suffers from a concussion experiences a denial
of these two sources of happiness and may exhibit signs of
depression. We should not over react and diagnose the
student-athlete with depression simply because he is feeling unhappy
due to the fact that he is no longer able to participate in his
sport which gave him not only a sense of purpose but also raised his
image tremendously in the eyes of his peers.
If you notice that the student-athlete looks depressed or comes
to school in a sad mood, talk to him/her. Try to encourage the
student-athlete to gradually get involved in the activities he/she
was interested in before the injury. Try to find ways to motivate
the student.
It is extremely important for teachers to observe for signs of
depression because lack of motivation, lack of energy and a feeling
as if life is not worth living can lead to thoughts of suicide in
adolescents. We must do everything possible to encourage the
student-athlete to look at the positive side of things and focus on
rehabilitation and recovery, not despair and hopelessness.
Gradually, the
student-athlete will take on more and more of the workload,
increasing the amount of concentration as long as there are no
recurring symptoms. Eventually he/she will build up to a full
workload without any symptoms as the original injury heals.
By the time the School CMP Leader is prepared to issue a School Clearance to Resume
Physical Training the student-athlete should be able to handle
a
full workload without accommodations.
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