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CONSULTATION SERVICES 
Personal Consultation Services
For Student-Athletes With
A Sport-Related Concussion

Unique Rehabilitation Program 
Designed to Help Your Child 
Return to School

School and Home Rehabilitation Plan Will Be Worked Out With Classroom Teachers

Specific Strategies Designed to Reduce The Risk of Repeat Concussions

Contact Robert Kirwan For More Information About These Services
(705) 969-7215 or 
(705) 586-PURE (7873)
or email

rkirwan@infocomcanada.com
 

HOPE FOR TOMORROW
Concussion Management
Program Development
Workshop 
For School Boards
& Minor Sports

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Concussion Management Consultation Services
For School Boards

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Concussion Management Consultation Services
For Minor Sports

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CMP Program Development Guide
Click for a free PDF copy of the Book

Program Development Guide 
Excerpts
What is a Concussion?
Signs, Symptoms & Behaviours
A Partner Approach
Understanding The Brain
Essential Elements
Baseline Assessment
Concussions & The Law

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012
British Journal of Sport Medicine with Links to Related Reference Articles
PDF Download Copy
Review of Statement by CMP
SCAT3
Child SCAT 3
SCAT3 - Pocket Version
Sport Concussion Library
ImPACT Test Web Site
Other Links and Articles
 
GUIDE FOR TEACHERS
TEACHERS' GUIDE TO ACCOMMODATING STUDENT-ATHLETES SUFFERING FROM CONCUSSION
   
INTRODUCTION
by Robert Kirwan
 

The CMP Student-Athlete Concussion Management Program recognizes that during the rehabilitation process a student-athlete will still be expected to meet certain responsibilities as a student. 

 

While it may take several weeks or longer before a student-athlete is clear of concussion symptoms and can return to physical training, we understand that it may not be feasible to keep the student out of class for that length of time and expect the student to successfully complete his/her course requirements.

  

Because of this, we have prepared a general Guide for Classroom Teachers that will help you make certain that the appropriate accommodations and adjustments are made for student-athletes with sport-related brain trauma. 

  

IMPORTANT ROLE TO PLAY

  

Whereas a concussion is an injury that results in physical, cognitive, psychological and emotional symptoms and dysfunction, we feel that a classroom teacher will also be in an excellent position to recognize signs of lingering symptoms that must be considered before allowing a student-athlete to return to physical training. Because of this, we have recommended that the School CMP Leader or designate,  consult with the student-athlete’s classroom teachers and/or guidance counselors before giving his/her final School Clearance to Resume Physical Training or to Resume Athletic Competition. This means that your expertise and knowledge of your students will be recognized and your input will be very important to the future of the injured student-athlete.

  

As a Classroom Teacher, you and the student-athlete's parents/guardians may very well become the most important people in the rehabilitation process. You know what your student was like before the injury. You know what his/her "baseline" was with respect to his/her performance level in the classroom. Therefore, you will be able to easily spot differences in cognitive and emotional function far more quickly than anyone else. After all, the student-athlete spends six hours a day, five days a week at school. He/she spends the same amount of time at home not counting the time spent sleeping. Therefore, who is in a better position to be able to determine if the student-athlete is functioning differently after the injury? Who is in a better position to be able to conclude when everything appears back to normal?

 

There is no doubt that health care professionals play an important part in the identification and rehabilitation process, but doctors will only be able to determine if the injury produced structural damage such as a fractured skull, swelling of the brain, internal bleeding, or damaged neck muscles. An emergency room doctor will not be able to tell much else. A teacher can tell if there are academic deficiencies. A parent can tell if there are emotional deficiencies or sleep problems.

 

DO NO HARM

 

This Guide for Classroom Teachers will also help ensure that you "do no harm" to your students while they are gradually returning to normal classroom functions. It will also help you determine which accommodations and adjustments may be necessary in order to help your student cope with his/her difficulties and challenges while avoiding any chance of  inadvertently causing stress on the student's  brain that may delay or impede rehabilitation.

 

In fact, many studies and testimonials confirm that concussion symptoms can be greatly acerbated by the daily stress and anxiety caused from normal, everyday classroom activities. The increased electrical impulses and chemicals that are produced as the student-athlete strives to keep pace with the rest of the class can cause just as much damage as further physical contact in competition. Therefore, CMP Concussion Management Partners Inc. will always recommend taking special precautions to make sure that classroom teachers are fully aware of students in their care who may be experiencing a concussion.

UP TO 20% OF PARTICIPANTS WILL BE CONCUSSED EACH YEAR

It should also be noted that for most designated contact sports activities, an average of 10% of the participants are expected to suffer some degree of head trauma resulting in concussion during any given season. The rate increases to as high as 20% or more for some of the more physical sports such as football, rugby, and hockey.

Those statistics imply that with physical sports such as hockey and football, where the rate of concussion among participants can be as high as 20% per year, every student-athlete who takes part in these sports for a period of more than six (6) years will most likely suffer at least one concussion. Some experts predict that at least 1/3 of the participants will have experienced at least one concussion, but many others feel that the rate will be at least 2/3 based on what we are finding out about concussions.

Further, from what we are learning about concussions, it is quite likely that most if not all participants will also have suffered numerous subconcussions during the same period. The implications for the classroom are significant for secondary school student-athletes since many of then will  have been playing their sport of choice for at least eight or more years. They may be extremely vulnerable to life-altering consequences of improper rehabilitation procedures, so the classroom teacher can actually have an extremely positive impact on the student-athlete's entire future simply by making a few simple adjustments in the classroom for a couple of weeks.

A CONCUSSION IS A CONCUSSION 

We should also indicate that there is no difference between a sport-related concussion and a concussion that is caused from a fall or an accident. The information in this Guide is appropriate for all students with concussions that you encounter in your classroom. Statistics will show that concussions are the most common injury for teens. In fact, most of the concussion injuries in society occur among teens and young adults, and these groups take longer to recover than other age groups. You can expect a lot of sport-related concussions, but you should also expect a number of non-sport related concussions.

Therefore, if you find out how many students are participating in sport activities during the year, you will have some idea of the number of students who may eventually be in need of some sort of accommodation because of their brain trauma injuries. If you find out how many students have been playing their contact sport for more than six years, you will also have a pretty good idea of  how many of them may have already had at least one concussion during their life and may actually be showing post-concussion symptoms without anyone even being aware of the situation. These post-concussion symptoms may be permanent and may have simply become part of who the person has become - for better or for worse.

The thing that is important for teachers to remember is that no matter how the injury occurred, a student with a concussion may require some significant accommodations and adjustments in the classroom for some period of time.

FOCUS ON RECOVERY AND REHABILITATION 

Keep in mind that while we accept that there will be some non-sport related concussions to deal with during the year, this CMP Teachers' Guide has been developed to assist classroom teachers in dealing with the accommodations and adjustments that may be needed for student-athletes who are recovering from sports-related brain trauma. We recognize that professional teachers are ultimately responsible for the well-being of the students in their room, so we welcome input from you if you find additional strategies that have worked and which you do not mind sharing with others.

During the rehabilitation period the student-athlete will be doing whatever he/she can to recover for athletic purposes, but he/she is still faced with the challenges of meeting regular expectations for class participation and homework completion. You should remind the student-athlete that he/she is in "training" to return to his/her "cognitive game" as well.

Until all symptoms of their concussion have cleared up and their neuropsychological function has returned to normal ( as evidenced by the post-injury ImPACT results ), many young athletes will have difficulty not only with their academic work but also with their interpersonal interactions with peers, parents and teachers. You may have to intervene at times to deal with these interpersonal conflicts in order to reduce the "stress load" on the student-athlete's brain. You may also have to counsel your student so that he/she realizes that out-of-character behaviour may simply be another symptom of the concussion that will go away in time.

Sleep disruption may cause fatigue leaving the student-athlete with very little mental energy to participate in a full day of classes followed by hours of homework. That is why homework should be limited or eliminated, at least for the first while.

Some student-athletes will try to hide their symptoms for fear of appearing weak to their teammates, but the cognitive deficits still remain and they will struggle to keep up despite their efforts. Classroom teachers will have no difficulty recognizing this. Classroom teachers who know their students will be able to spot the changes that persist and will recognize symptoms that remain.

PHYSICAL AND COGNITIVE REST ARE BOTH IMPORTANT

The most important point we make with teachers and parents/guardians is that the student-athlete will always recover more quickly and completely with both physical and cognitive rest. You can't put more priority on one or the other. They both work together.

This type of injury is not like a sprained ankle where you can focus on physical rest while continuing to maintain the regular academic demands of being a student. To complicate the situation the symptoms of a concussion may linger on for weeks or longer, so it is not easy to catch up on work by putting in more time at home. This stress and added pressure may actually worsen the symptoms and delay recovery. For that reason, we strongly recommend that during rehabilitation a student-athlete avoid homework or any assignment that might overstress the brain.

The main goal, therefore, is to give sufficient support to the student-athlete so that he/she can keep up with classroom responsibilities in a way which will not overstress cognitive functions. A temporary individualized education plan (IEP) that incorporates specific accommodations which can gradually be removed as the student-athlete progresses in his/her recovery is an ideal way to handle this situation. These accommodations need not be extensive and/or expensive and can usually be handled quite easily by the classroom teachers.

In particular, this Guide will enable the classroom teacher to play a crucial role in the assessment of the student-athlete's recovery progress by the manner in which the student performs in class. 

UNDERSTANDING WHAT HAPPENS TO THE BRAIN IS IMPORTANT

Brain research is still searching for answers to help us better understand the full impact of concussions, but what we do know from a number of studies is that student-athletes who suffer two or more concussions report mental problems at much higher rates than normal. These problems include headaches, dizziness and sleeping issues. The scientific term for these symptoms is "neural precursors" which are signs that something has gone seriously wrong with the functioning of the brain. Classroom teachers must be on the look out for these neural precursors.

A study that was done in 2004 found that football players with multiple concussions were up to 8 times more likely to experience a significant drop in memory performance and even three months after the injury they continued to experience difficulty with the processing of visual stimuli. These problems will have a negative impact on a student-athlete's academic performance and may end up denying him/her of the marks necessary to enter into the university program of his/her choice.

A better understanding of what really happens when the brain suffers a trauma that leads to a concussion is necessary in order for a classroom teacher to fully appreciate the importance of adopting strategies and accommodations that will avoid causing further damage to the student.

Immediately after the trauma, in the milliseconds that follow, there is a tremendous release of neurotransmitters as billions of brain cells turn themselves on at the same time. This causes a power surge of electricity in the brain. However, that is not the problem. As soon as this power surge is over, the neurons try to restore the equilibrium in the brain and get back to normal. In some cases this process can take hours. In other cases it can take days, weeks or the damage can be permanent. We do know that most student-athletes with concussions need between 10 and 14 days to recover. During this recovery period the student-athlete can suffer from a wide range of symptoms and any further physical and/or cognitive stress or trauma can make matters worse and delay recovery. The symptoms are the brain's way of telling the student-athlete to take it easy so that the neurons can continue to focus on recovery of the damaged cells and neural infrastructure.

The important thing to remember is that the healing process that goes on inside the brain must be continuous and without interruption. That is why second concussions are so common among student-athletes who return to play too soon or who place too much cognitive stress on themselves by trying to get back to normal levels in the classroom. The neurons are still experiencing an energy crisis as they are trying to recover. So if the brain experiences another trauma, even if it seems minor in nature to the first one, the damage may be much more severe. Another "power surge" can destroy recovering brain cells causing a massive loss of neurons that is permanent.

NOTIFICATION OF TEACHERS

Of course, a teacher can't do much if he/she isn't aware of an injury. Therefore, one of the responsibilities of a School CMP Head Coach and the parent/guardian of the child  is to make sure that all of the classroom teachers who work with the student are notified of the injury. 

The child's parent/guardian should be sending you a special signed Notification To Teachers form that will contain some important information, most of which will be addressed in this guide, but it will at least notify you of the injury and the need to address some accommodations for the child.

This notification should also be given even if the symptoms seem to be very mild. As we will see in the rest of this Guide, there are many things in the classroom that can make concussion symptoms worse and it is possible that serious consequences can result from seemingly simple activities in the classroom that may aggravate the recovery process that the brain is undergoing. So even if the symptoms seem mild to the parent/guardian, it is still important that the teacher be aware of the injury in case the demands being made on the student-athlete actually cause further damage. It would be a shame if the "second impact" concussion came as a result of a "cognitive force" being felt by the brain and not from a "physical force". As strange as it sounds, it could happen.

AVOID PLACING STRESS ON DAMAGED AREA OF THE BRAIN

You may find it easier to understand what is happening to the brain during this recovery period if you compare the injured brain to a sprained ankle. For example, there are varying degrees of ankle sprains. Some are mild and some require a cast and crutches. However, the best treatment for any ankle sprain is to rest and avoid using the ankle more than necessary. Eventually the pain will subside and the damaged area will heal. However, even once the pain seems to have gone, the ankle is still extremely vulnerable to being reinjured. Therefore, if a person returns to activity too soon, it is quite possible that the ankle will be sprained again, only this time the damage may be much more severe because of the original injury making that area of the body more susceptible to injury.

The exact same thing is happening to the brain. The concern in this case is that the brain is attempting to heal an "electrical circuit" that was damaged in some physical trauma. So, while the brain is devoting energy to repairing or reconstructing the damaged area, it needs to avoid any further electrical or chemical aggravation. When a person suffers from a concussion we all understand the need to avoid physical activity that may result in further physical damage to the brain. However, we may not fully comprehend the damage that can be caused by simple things we take for granted, such as completing assignments and homework, studying for tests, playing video games, etc. All of these activities require a tremendous amount of electrical and chemical reactions among the millions of neural connections involved in the activity. This energy demand will reduce the energy required by the brain to repair the damaged areas that were experienced by the original brain trauma. Further, the activities may cause increased stimulation of the damaged areas. This produces the same result as running on a sprained ankle before it is completely healed and returned to full strength through exercise. If the damaged area suffers another physical or cognitive trauma before it has healed and allowed to strengthen again, the damage may be even more severe than the original injury.

STRESS HAS GREATER NEGATIVE EFFECT ON ADOLESCENT BRAIN

We know that stress has a negative effect on brain development and secondary schools are a hot-bed of stress to begin with for adolescents. We also know that while the brain becomes hardwired as information and skills are repeated to form memory, its built in neuroplasticity makes the brain susceptible to change as well.

Therefore if an injury occurs to "strong" neural connections, symptoms may be more pronounced and last longer since the brain will have come to rely upon the first level or automatic pathway. It may take much longer for the brain to build new connections that will enable functionality to return to near baseline levels. Even though it may take longer, that may be an easier way for the brain to recover than trying to heal the once strong connections that were damaged by the brain trauma.

As for the student-athlete going through rehabilitation, frustration tends to set in quickly if you have difficulty performing tasks that were very strong and automatic before the injury. This causes stress and anxiety which prolongs the recover and leads to more stress and anxiety. That is why we simply cannot emphasize enough the need for both physical and cognitive rest in order to allow the brain to re-engineer itself and restructure the connections. If the student-athlete is allowed to return to play too soon or if he/she is expected to return to pre-injury levels of learning in the classroom, then stress and emotional problems will result in the brain releasing chemicals that will prolong the recovery and cause further damage to the neuronal connections.

The part of the brain that is responsible for emotions will, in all likelihood, be affected by the concussion since it is connected to just about all areas of the brain. It may not be the area where the brunt of the damage occurred, but is is common for it to be impacted in some way. This means that the student-athlete's ability to control his/her impulses will also be impaired. Therefore, you may find that the student-athlete gets frustrated more easily and becomes extremely upset when things are not going right. It is therefore extremely important for teachers and parents to allow the student-athlete to recover at his/her own pace. Do not put pressure on them to return to play or improve their learning skills. This will just cause more stress which will interfere with the brain's ability to develop new neuronal connections to repair the deficiencies.

BECOME FAMILIAR WITH REST OF THE SITE

Therefore, all teachers who have student-athletes who have a suspected concussion should be advised to read this guide so that they are at least aware of what to look for and of what might be signs that their student-athlete is symptomatic. Not knowing what you are doing in this can result in significant life-altering consequences to the injured student-athlete, resulting in him/her becoming a much different young adult than might have otherwise been the case.

In order to become more familiar with the CMP Student-Athlete Concussion Management Program, it is recommended that each teacher familiarize themselves with the information contained in the other sections of this web site. The more you know about the program the more you will understand how each of the partners in the process are working in the best interests of the student-athlete and you will see why we say that the classroom teacher has a tremendous role to play in the program.

We also suggest that it might be a good idea for the School CMP Leader (who is usually the school Principal) to conduct an annual workshop with his/her staff on concussion management. The contents of this page would be a good starting point for the material that could be included in the workshop for classroom teachers. 

   

GUIDE FOR CLASSROOM TEACHERS

ACCOMMODATIONS THAT MAY BE CONSIDERED

It is understood that each student-athlete who suffers a concussion may require different accommodations depending on the extent of the injury, the anticipated recovery period, the subject area of the class, etc. The decisions about which of the accommodations are necessary and appropriate will always be left to the classroom teacher in consultation with the student, his/her parent/guardian and guidance counselors. 

Our opinion is that we should be treating a concussion as a form of learning disability which should require the development of something similar to an Individual Education Plan (IEP) for the student-athlete. This will set in motion a process whereby the student-athlete will have his/her accommodations formalized and monitored, not only in the short term until the obvious symptoms seem to resolve, but also into the future just in case there are long-lasting post concussion symptoms that persist and have a significant impact on the student's progress. While it may not be appropriate to do a "full" IEP, it is a good idea for the classroom teacher to follow some of the process involved in preparing an IEP simply for his/her own organizational purposes in monitoring and documenting the progress. This report will prove invaluable to the School CMP Leader (Principal) when it is time to consider signing a Return to Competition clearance.

Keeping this in mind, at this time we will provide a list of reasonable accommodations that we feel might be considered when you find yourself with a student-athlete in your classroom who is recovering from a concussion.

The student-athlete's parent/guardian will decide when the symptoms have subsided enough to allow their child to return to school following the injury. In most cases, the student-athlete will be able to return to some limited classroom activity within one or two days of the injury.

This guide is therefore being provided so that you can effectively help an injured student-athlete go through a step-by-step progression that will enable him/her to RETURN TO LEARNING at the same level as before the injury. Keep in mind that this is a step-by-step progression and that each student will progress at his/her own rate. Some will return to their pre-injury level in a week or less, while others may take weeks or months. Your job is to make sure that you are only asking your student to do as much as he/she can without any return of symptoms. If symptoms return, then you will ease up on the demands and perhaps make more accommodations.

We consider the RETURN TO LEARNING to be just as important as the RETURN TO PHYSICAL ACTIVITY.

  
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.

 

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.
  

IMPACT OF CONCUSSIONS ON A STUDENT-ATHLETE'S EXECUTIVE FUNCTIONS

   

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.

CLASSROOM ACCOMMODATIONS

 
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
 

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.
  

These are just a few of the accommodations that you might consider if you have a student-athlete in your classroom who has suffered from a concussion. What you do in the classroom will have a tremendous affect on the student-athlete's recovery. 

Understandably, as the student recovers from the effects of the concussion he/she will be able to handle more and more of the normal workload until such time as he doing everything that was expected of him prior to the injury. By that time the rehabilitation should be almost complete and he/she may be back into competition.

 

CMP CONCUSSION MANAGEMENT PARTNERS INC.
Serving Canada & the United States
Offices in the Province of Ontario and the State of Michigan
www.concussionmanagementpartners.ca
email: robertkirwan@concussionmanagementpartners.ca    Phone: (705) 969-7215

DISCLAIMER: All content found on this web site is provided for information and education purposes only and is intended to provide viewers, participants, and other injury prevention practitioners with information and guidance that may be used in helping them make informed decisions about concussion management. This web site is not intended to provide medical advice and should only be used to support, not to replace the advice of a physician or other qualified healthcare professionals. We have tried our best to include accurate information in all sections of the web site, but we do not guarantee that any information is in fact accurate and true in all respects. You should always consult a physician or other relevant healthcare professionals for specific information on personal health matters,  to ensure that your own circumstances are considered. You are responsible for obtaining appropriate medical advice from a physician or other qualified healthcare professional prior to acting upon any information available at or through our website.

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