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The broadcast is now starting, all attendees are in listen only mode.
Hello everybody, my name is Brenda Eagan Brown and I'm very happy
that you all have logged in today to our Webinar, it's put on by the Brain STEPS Program
and it's called Concussion in the Classrooms; Returning to Learning.
This is my contact information, you all have it on the slide handout,
if you ever need to get a hold of me, my phone number and my e-mail address are both on here.
We are going to hold questions today until the very --
well I don't even think we're going to get to questions today;
we have so much information to cover.
So what we're asking is that at the end, if you have any questions at all, feel free to call me
or e-mail me, and I will be more than happy to answer every single question posed.
So the objectives for today are to understand concussion signs and symptoms,
learning impacts of a concussion on students, Kindergarten through 12th grade.
Identify symptom based adjustments and accommodations to manage recovery within school,
explore the concepts of adopting the PDE/Brain STEPS,
concussion return to school protocol for learning.
District assistance with the implementation of this concussion return to school protocol
and concussion training will take place during a separate training
that will be discussed later in the Webinar.
And also to identify the importance of utilizing the Brain STEPS consulting Team
at four weeks post-concussion or earlier for more complex concussions.
Now my name again is Brenda Eagan Brown and I am the program coordinator
for the Brain STEPS program, so I want to take a few minutes and talk to you
about exactly what Brain STEPS is, and then we're going to jump right
into the heart of today, concussions.
So Brain STEPS stands for Strategies Teaching Educators, Parents and Students, it's the child
and adolescent brain injury, school re-entry program, the program is jointly funded
by the Pennsylvania Department of Health and the Pennsylvania Department of Education.
It's implemented by the Brain Injury Association of Pennsylvania and it has been
so since 2007 when it first began.
[Background Sounds] So what exactly is Brain STEPS,
we're brain injury consulting teams available to families and schools throughout Pennsylvania.
We cover the commonwealth with teams that are based out of the intermediate units and also
out of three larger school districts.
Our teams are extensively trained in the educational needs of students returning
to school following brain injury and our teams consult with
and train local school staff to develop educational programs.
Oh this is very important to know about the Brain STEPS Program, we work with any student
who has a brain injury that has been acquired after birth.
So that includes traumatic brain injuries, including concussions
and non-traumatic brain injuries, such as strokes, tumors, aneurysms, chemotherapy
and radiation effects on the brain.
So any student that you have that's impacted
by an acquired brain injury can be referred to the Brain STEPS Program.
This is a list of the consulting that our Brain STEPS Teams regularly do with families
and we keep track of, you know, the minutes spent and everything
and how many complications are occurring.
This is to give you a good idea of exactly what the teams can do
and how they can benefit your school district.
A question we get a lot is "who should be referred to Brain STEPS" --
oops very good question, let's just go right back to it, okay a student with an old
or a new acquired brain injury, so it could've happened when the student was two years old
and now they're 12 and having issues in school, or it could've happened last week
and they're still in the hospital or in rehab and you can make a referral for them.
The brain injury has occurred after birth and the brain --
a Brain STEPS referral can be made while he or she is enrolled in school
at any point in time until they graduate.
Now if a student has a concussion, we do ask the districts wait
at least four weeks post-concussion to make a referral to Brain STEPS,
unless the concussion is more complex in nature
and we will explain the definition of complex concussions.
So now to the hardest things, which of these students pictured here has sustained
Well we don't know and that's because most of concussions are --
I mean most symptoms and signs of concussions are invisible.
Most students after concussion do not return to school with a bandage on their head.
Again the signs tend to be invisible,
so it's good to know what exactly the signs are of concussions.
I'm sure all of you today are attending the Webinar because you have
or are currently working with students who sustained concussions
and maybe aren't getting better as fast as you know,
some other students who've had concussions, so you're probably here today
to learn what can your district do to better educate these students
and support them while they recover?
So first I want to talk about some statistics.
The Centers for Disease Control estimates that approximately 3.8 million sports
and recreation related concussions are estimated to occur in the United States each year.
Now this is all ages -- 3.8 million.
Annually, in the state of Pennsylvania, approximately 22,000 children ages zero
to 21 years, sustain concussions.
These are children that has been seen in either the emergency rooms or in hospitals.
This number does not account for the children who are not seen by a medical provider,
or are not -- who do not go to the hospital or who just go to their regular pediatrician,
they're not counted in this number.
The majority of students -- of anybody after a concussion will recover
within the first three to four weeks.
But until they're recovered, students should receive accommodations
in all settings to promote cognitive rest.
For students who linger with their concussion, striking that balance between the need for rest,
to recover and keeping up with academic content seems to be the biggest struggle that parents,
families, students and school districts struggle with.
And that's why the Brain STEPS Program is really focusing
on concussion management within the schools this fall.
Now a concussion is a mild traumatic brain injury.
The term is synonymous, sometimes you'll hear it referred to as a mild head injury,
sometimes you'll hear it referred to as a mild traumatic brain injury,
but all of those terms mean the same thing, they all mean concussion.
Concussion derives from a Latin word which means to shake violently.
There are many, many concussion definitions,
the Centers for Disease Control actually is meeting today to try to come
up with a universal concussion definition.
But this definition really sums it up quite basically and quite nicely.
A concussion is a type of traumatic brain injury, caused by a bump,
blow or jolt to the head that can change the way your brain normally works.
Concussions can also occur from a blow to the body that causes the head to move back
and forth rapidly, now what this means is that your head does not have
to actually hit something, so picture someone that is restrained in a car by a seatbelt.
If that car wrecks, the person may not hit their head on the windshield
because they're restrained by the seatbelt, but their head is still going to jerk back and forth
in a whiplash motion and that's all it takes to cause a concussion.
And this is exactly what I'm talking about.
So what exactly happens during a concussion?
If you look the brain of an adult is about three pounds in weight, and it sits inside
of cerebrospinal fluid and it's -- the brains consistency of the -- is of like a hard Jell-O.
Oops -- so what the brain does is upon impact whether it's --
you know, front to back or side to side where this picture shows front to back --
I can't get it to work again, you can see the areas of the brain that light
up red are the areas that are being damaged.
So just because a student hits their head in the front part, does not mean that the back part
of their brain has not been damaged and vice versa if it occurs on the sides of the brain,
because the brain reverberates, it bounces inside the skull.
And speaking of skull and this is a picture of the inside of our skull, it is bony and jagged
and has ridges, so you can only image what could happen if the brain is suddenly jolted inside
and it hits any of these ridges, it can produce sheering
and tearing of the neurons in the brain.
Brain tissue that is damaged does not regain lost function, but that does not mean
that a student can't compensate for things that have been lost, or the brain could recruit
and recruit other areas of the brain that have not been damaged,
to do the same function that maybe was damaged before.
So following concussion, what we've learned in the past several years,
is that there are actual metabolic chemical changes that take place in the brain.
So this is a picture of normal neuron.
A neuron is a nerve cell and we have 100 billion neurons in the human brain.
The neurons essentially connect with each other where the synapse is --
so if you see that word, that says synapse right here.
So messages come down the neuron and they jump the synoptic cap
and this is how we make connections, we learn.
There are approximately one quadrillion synapses in the human brain.
Like it's impossible to even imagine how many that is,
but for now we're looking at one, one healthy neuron.
And what typically occurs is the signal arrives at the neuron, it travels down the axon
from one cell to the other and neurotransmitters are released in a organized manner,
right at that synoptic gap, triggering the next cell message with a specific coded message.
Now during a concussion, the calcium ions actually rush out of the cells
and they're not supposed to do that.
Toxic calcium ions rush into the cell and this leads
to what's called a metabolic or a neurometabolic dysfunction.
It causes a metabolic energy crisis in the brain and this is
when students start experiencing symptoms.
There's a massive release of neurotransmitters that interfere with cell communications.
During this time period it is extremely vulnerable, the brain is very, very vulnerable
and further injury or stress may cause cell death or serious cell damage.
This is why students, it's so important that they are removed from play, if they're injured
in a sport, because it will take much less force during this period of energy crisis
in the neurons, to constitute a second concussion -- much less force.
It may take many days for the nerve cells to return to their normal condition
after several days, starts to get back to normal, after many days,
sometimes it takes several weeks, we go back to a normal neuron, which is where we want to be.
Let me go back to this -- so essentially what we just talked about then,
the potassium's exiting the cell while the calcium's entering
and when the calcium enters the neuron, it essentially shuts down the cell
and causes what's called vasoconstriction.
And the constriction decreases blood flow,
now neurons need blood flow to survive, it's their oxygen.
And when blood flow is restricted at the exact same time that the blood --
that the brain needs more blood flow for recovery, this is when students start
to experience a lot of symptoms, again this can last for many weeks.
This is a slide I added in today, because I think it's really key and important to show you
that on the left side is a concussed frame, in the middle is a severely,
traumatically brain injure brain, of someone that was in a severe car accident,
they are in a coma for the past three days when this scan was taken.
And they are nonresponsive.
And then a normal brain on the right.
The red indicates high brain metabolism,
blue indicates low brain metabolism or low brain activity.
If you look at the difference here, the mild head injury, which is a concussed brain,
and the severe head injury, internally there is no red here.
So they are equivalent to each other in what is going on inside
of the brain, neuro metabolically.
Okay so the metabolism is not -- it's not -- the brain is not working like it should be,
so even though students were concussed, we might not be able to see it, there are things going
on in the brain, I just want you to be aware of that.
A brain injury can occur and typically does, even if there is no loss of consciousness.
Initial CAT and MRI's scans are likely to be very normal, so you know,
a lot of times students will get CAT scans at the hospital in the emergency room
and typically there are no findings.
Concussions don't show up on CAT scans or MRI's.
More than 90% of concussions do not involve any loss of consciousness.
Instead something that's really good to look for,
after a student has been initially concussed, is do they remember things right before
and right after their concussion?
This is a much more accurate assessment of how severe their concussion is,
than whether or not they lost consciousness.
[Background Sound] Now all concussions are serious, no matter the severity.
Eighty to 90% of concussions do resolve during the first four weeks.
Which is great, that means the majority of the students that are coming back to school,
you are going to see rapid improvements during the first four weeks.
And then the majority of those kids should be better.
In some cases symptoms do persist for much longer and about 5
to 10% symptoms do last for a lifetime.
Now these are the signs and symptoms of concussions from the Centers
for Disease Control, which is a lot of the information that we use
for the Brain STEPS Program, comes from the Centers for Disease Control.
So thinking and remembering there are four silos essentially of symptoms,
thinking and remembering, the student may have difficulty thinking clearly,
they may feel slowed down, sometimes they say they feel like they're in a fog and students
who say they feel foggy or dizzy, actually those two symptoms --
students with those two symptoms, sometimes linger longer,
so that's kind of a key to look for.
Do they say foggy, do they feel dizzy?
They may have difficulty concentrating, they have difficulty remembering new information.
As for the physical signs and symptoms, headaches,
number one thing that we see, are students with headaches.
They may have nausea or vomiting early on, so right after they're concussed, you know,
within the first few days especially, balance problems
and dizziness are extremely common also, fuzzy or blurry vision, feeling tired
and having no energy and then insensitivity to noise or light.
And a lot of people don't know that that's a major sign
of concussion is sensitivity to noise or light.
Also mood, emotional symptoms, the student will be more irritable,
will probably display some symptoms of sadness, more emotional and experience more nervousness
or more anxiety -- then it's typical.
In their sleep, they will either be sleeping more than usual,
sleeping less than usual, or have trouble falling asleep.
Now a student only needs to have one of these signs, that was not present prior
to hitting their head, to demonstrate that they have a concussion.
So it's really important if we have school nurses on here who, you know,
usually are at the front line of seeing students injured, one symptom could signify a concussion.
Now our teachers may observe some other things.
They may observe multi-tasking difficulty in the classroom, forgetfulness more so than normal,
the students thinking and processing may be slowed,
they could have difficulty handling new situations, maybe they are more --
maybe they explode now, when before they could handle things and transitions better.
Word finding problems, teachers see the pain
and symptom levels influence the student's performance in class.
The student can frustrate easily, be unable to cope with stress, exhibit behavior
or personality changes, answer questions slowly, repeat more than normal.
The student may display confusion about the daily schedule, assignments -- environment.
We've had students that go back to school, a few days after their concussion
and all of a sudden they cannot remember their locker number or they can't remember
where their locker was, or they can't remember what class they go to first period.
Also being much, much more emotional than usual,
so acutely that's right whenever the concussions happening, the managements just like --
much like a student who's missed a few days due to a minor illness.
Most kids will be off for a few days, when they come back to school;
hopefully their concussion will be resolved or resolving.
Now while the student is home, they should not be doing homework as make-up work,
because they have to be on total rest, and we'll talk more about that.
If concussion symptoms do linger, they must be properly managed, so the student can remain
in school, attending classes, fully accommodated.
The last thing we really want to see are students who have to go on homebound for weeks
or months at a time because of a concussion, and we strongly believe
that with appropriate training and consultation, in concussion, everyone's on board
to provide the right accommodations to the student needs, their recovery can occur faster
and it can take place in the school building.
Now there is no set timeline for concussion recovery.
Every single student is different, typically though a child will recover from a concussion
as long as their brain has had time to fully heal.
It's very important that after a concussion, students are excused immediately,
from all sports and sporting events, like participating in practices, scrimmages, games,
conditioning, they should be excused from all of that.
They should be excused from physical education class, and they should also be excused
from physical activity during recess, the reason for this is because like we talked
about earlier, the brain is much more vulnerable while it's recovering
and it will take much less force to sustain a second concussion.
And when you sustain a second concussion, before the first concussion has healed,
it can cause a lot more damage in the brain, a lot more; it can last longer
and be sometimes lifelike impairments.
Now the student should be excused from these three things until they're symptom free.
And we don't just say symptom free in general, we have three categories that the student has
to be symptom free -- at rest, they have to be symptom free with physical activity,
and they have to be symptom free with cognitive exertion, that means while they're thinking,
like in school, they have to be symptom free.
The student should be -- or has to be cleared by a physician with experience
in concussion management, now we're not going to get into the return to play law,
because there are other trainings for that available, we are talking about return
to school, but there are appropriate medical professionals that are outlined in the return
to play law, act 101, if you're interested in the specific details of that.
Now important, while students are excused from these physical activities,
mental work should not be substituted for physical work.
And what this means is if a student's excused from P.E. Class,
they should not be sitting there outlining a book chapter on health.
You know it sounds like, you know, okay that makes sense, but a lot of people might do that,
so make sure that mental work is not substituted,
they should be completely resting during that class.
Now what we know based on research, is that total physical and cognitive rest is crucial
at the acute phase of brain injury or concussion.
That means that the initial time, after a concussion,
should be spent at home on total rest.
So if that student has symptoms, if they have a concussion right after they're concussed,
they should be at home resting for about one to three days.
Resting means no TV, no texting, no video games, no reading, no parties,
no cell phone, no computer, no loud music.
Anything that would stimulate the brain, it's hard to any kids or teenagers that they have
to be on total rest for a few days, but they really need to follow this, because the students
who follow this and go on total rest initially, are -- they're way better --
a lot better than students who jump right back into school and push through their symptoms,
because that's the worst thing you can do for a concussion, that will delay recovery
and that will exacerbate symptoms.
So we don't -- the one time that we want to tell kids, don't push through your symptoms,
when you have a symptom, stop what you're doing and rest.
Students -- and here we go, students should not push through symptoms while recovering,
because it does two things, it exacerbates symptoms and it can prolong recovery time.
Instead what we want to do is when students come back to school immediately;
we want a frontload accommodations to avoid prolonged recovery.
Experts in the field of concussion have come to the realization
that cognitive demands can actually worsen symptoms and delay recovery.
So what's happening is the brain is using all of its energy to recover after a concussion.
When a student comes back to school and is trying to think, they may get really tired,
they may get a headache, they may get dizzy,
because their brain is recruiting neural resources just to recover So to try and think
on top of that is cognitively exhausting for the brain.
Think of a sprained ankle, when you come back to school,
the P.E. teacher wouldn't have a student run around the track on a sprained ankle,
because it needs rest to recover.
And the same thing goes for the brain,
when we know someone's been concussed, the only medicine is rest.
In the very beginning, total rest, in the very beginning.
So that that brain can use all of its neural resources to recover.
So how can we help the concussed student?
Why are we here today?
Well first concussion management within the school,
must flow between a lot of different entities.
So it should flow from the school team, to the physician, to the family, to the student,
to the coaches in the athletic department, if it's an athlete
and if the Brain STEPS Team is involved, also to them.
It needs to be an open flow of communication.
While it's true that an athlete must be 100% symptom free before returning to play,
this student does not need to be 100% symptom free before returning to learn.
And that's why we are here today to talk about in a little bit, the return to school protocol
for students who have concussion.
And again it's striking that balance between the need for rest,
while keeping up with academic content that is the biggest struggle for dexrinate students.
Two things that you don't want to happen after a concussion, first you know,
as we said you don't want to get hit in the head again,
because [inaudible comment] will have far worst outcomes, and second the increase and demand
for energy to quickly -- like thinking and concentrating, can extend the recovery process.
Now when a student comes back to school, they may be at home for a day, two days, three days,
some students are home for a week, hopefully they are being managed
by a doctor familiar with concussions.
They could -- they may seem like their symptoms are going away, but watch, because many times
when they come back to school, it's the thinking with the added stimulation
of the school environment, it can really significantly increase symptoms,
even when they've begun to recover at home.
So keep an eye on that with students, let them know, make sure the student is aware that this,
you know, could happen and if so is that it is a common occurrence.
Now there is no research based return to school progression.
There is a lot out there that talks about best practices
and I'm going to talk about that right now.
So essentially first there should be no school initially.
If a student is home for a day, two days, three days, sometimes a week --
again this is under doctor's orders, hopefully, no homework should be sent home.
And again that's because the student is home and their only job is to rest.
Their job is not to be a student while they're home resting, it's just to rest.
When a student -- or the student should be aware and know that missed work should not be expected
to be made up as soon as the student returns to school.
Well because if the student is making up work and trying to keep up with schoolwork
when they come back, that is overexerting the brain, so step two, after the students home
with no school initially, step two is about a half day school with accommodations.
Now some people say okay, so what is the transition point?
So how do we know when a student's ready to come back to school?
A lot of the experts in the field nationally, say that if a student, at home,
can concentrate for approximately 30 minutes, without becoming symptomatic,
without getting headaches, without getting tired, then they're ready to come back
and start school -- start it back with half days.
Half days doesn't need to be a month, half days can be two days, you know,
it's whatever the student can tolerate, maybe the student will come back one or two days
at half day and then they are ready for full day.
So step three would be full day with accommodations,
so we want all the teachers onboard with any, you know,
accommodations that this student needs.
And then step four is full school,
extracurricular involvement without accommodations.
So now the students back to normal and the school with the student should work on a plan
to complete any missing work and athletes should participate in graduated return to play,
only after clearance from approved medical professionals.
This is a typical school accommodation request form that many schools have seen from doctors
and different concussion clinics, and well we get a lot of calls on --
for the Brain STEPS Program to come in and help with is they will see this lesson,
homework load, by 60%, that's extremely common, and we've even had some that say, by 75%.
It's pretty easy for a school to figure out how to lessen the homework load by 50%
for the first several weeks, four weeks, but once you go beyond that,
and you're asked to accommodate a student 50% of the workload and they may be in all A,
Courses and you're now at the five month mark, that's when things start to get very difficult
to maneuver and that's where the Brain STEPS Team can really step in and help your district,
because we get calls like this all the time where we help student referrals.
So 50% of workload is a common recommendation during recovery and it is a good recommendation.
It's a good recommendation especially during those first four weeks,
so essentially the student would be responsible for completing 25
of the 50 math problems assigned.
But the key to this accommodation is ensuring the student has the key concepts
for that day mastered.
So maybe the student has it mastered in the first five problems
and then they don't need to do the rest.
Cut the repetition.
Assignments like homework and class work, should not be repetitious, remove any nonessential work
and grade work completed versus work needed.
Now there are two categories that makes it really nice for teachers and students to sit
down and say okay, we know that you have a lot of homework that you missed while you were out,
or we know you're having trouble keeping up, so let's go through and make a list
of all the work you've missed, what can be excused and what you are responsible for.
This sounds very simple, but a lot of people don't do that.
And then everyone gets confused on what's due, what's not due, what's responsible --
you know, what the students responsible for, what they are excused,
so making a list per class with the teacher is really helpful
and it helps the student know exactly where they're at.
Now cognitive fatigue and headaches are common and we do a lot to alleviate this,
but I basically, not having a student think as hard as they would have too, so for instance,
providing the student with a checklist, providing a student with a task analysis list,
that tells them step-by-step how to do a homework problem You know,
first you do this, then you do this.
Graphic organizers, schedules, fact sheets, anything that the student can have in front
of them, that can help clue them in to what an answer might be, so they don't have to spend all
that cognitive energy retrieving things from their brain, because that is taxing.
And again the whole purpose is helping the student rest
after concussion, but yet remain in school.
So what we want to know is for instance, on an open book test,
what we want to know is does this student know the answer?
We don't want to know does the student know how to find the answer in the book?
So maybe we can tell the concussed student, on an open book test, maybe it's a whole unit,
maybe it's a unit test and we could say the answer
for number one can be found in lesson two.
The answer for number three can be found in lesson one.
That will significantly cut back on the stress put on the brain to find that answer.
And even Word Banks, again, we want to know does the student know the correct answer,
so having all of the words or all of the answers somehow in a Word Bank,
is less taxing on that student's brain, so they can look and choose the correct answer.
Also providing space for all math computations, instead of having the student do math
on one sheet and then you transfer the answer to a final page,
after a concussion just have them circle the final answer
on their scratch sheet, on their worksheet.
Give the page number in the book where an answer can be found next to questions for homework.
Breaking down assignments into chunks that can be completed in a half hour or less is very,
very helpful for students after a concussion.
Because many students will become overwhelmed and try to get all of their projects done,
or assignments done, so it's helpful if the teacher could work with the student
and just break it down, okay get this done in your first half hour tonight.
Tomorrow night get this done in this half hour, you know, break it down.
Water bottle at students desk, a lot of school's don't allow water bottles,
but we have found anecdotally that having a water bottle
at a student's desk sometimes can help with their headaches.
Also setting a timeline to plan for projects, then a student can, you know,
how much time they have left and how much -- how soon they need to initiate beginning.
A tape recorder for lectures, this accommodation we recommend more
than anything else besides reducing the course -- the workload.
The student may need to take brief in-class or out of class scheduled rest breaks,
maybe in the nurses office, somewhere quiet, every hour, every period for about 10
to 15 minutes while symptomatic initially.
So what this means is the student -- it shouldn't --
you know, we shouldn't tell the student when you feel tired,
when you feel like you need a break tell the teacher, because when a student feels
like they need a break, they're already symptomatic and it's too late.
The whole purpose of keeping the student in school is to keep them
at below their threshold for symptoms.
So we the student to be completing work in all of their classes,
but yet keep them below their individual threshold, we don't them hitting that headache,
we don't want them hitting that dizziness, we don't want them hitting the fatigue level.
So if we schedule rest breaks that is very, very helpful.
Testing or working in a separate, quiet room, also helpful.
Now acutely the first one, two weeks, three weeks, testing --
tests and quizzes should be delayed, especially standardized tests if you can.
Gradually introduce testing, preferably one per day as tolerated and then increase from there.
For sensitivity to light and noise, which is very, very common,
allow the student to wear sunglass, or a wide brimmed hat, check their schedule, you know,
are they in band or shop class, loud places,
chorus any of those they should probably be excused from while --
during the first few weeks, because it will exacerbate their symptoms, the loudness.
Now no cafeteria, some students can't eat in the cafeteria
because of the lights and the loudness.
So they can go with a few friends to the Guidance Office and eat, but what we don't want
to do is pull them out of the lunchroom, you know, for a long period of time completely,
because especially in the high school level,
that's the only socialization kids get is many times in the lunch room, the cafeteria.
So even if the student could go and eat there for maybe 10 minutes or 15 minutes
and then remove themselves once they're done eating to go in a separate area,
[Background Sound] because we do have to be aware
of this social impact a concussion has on students.
Move the student away from windows and warn before tornado drills or fire drills.
Now for dizziness -- which is also called vestibular problems,
allow the student extra time to get to class before the halls become busy,
let them walk with a peer or carry books -- let the peer carry their books.
And also the teacher, if they can provide the student with notes to prevent the up
and down shifting of the students eyes from the board or the screen
to their notebook, would be very helpful.
But yet the student can still remain engaged if they have a highlighter to follow along
and highlight like key concept recognition.
So we still, again, you know, we want to try to keep the student engaged, but yet we don't want
to throw them into their symptoms.
Now social emotional, this isn't always thought about a lot after concussions,
but the Brain STEPS Program really puts a big focus on this, early on students --
the majority of students worry about school in general, falling behind in academics
and not being allowed to return to sports.
Later on, for students that are lingering past four weeks, we start to see signs of anxiety,
depression, adjustment issues, and social isolation.
So please be aware and watch these students, because I get the question all time, you know,
how do you aren't malingering, how do you know these students aren't just saying this
to get out of doing their class work?
And I always say, you know, we do have students that fake, there are of course --
there are some students everywhere that would fake this.
But how many kids do you know want these restrictions put on their life, not many.
So keep that in mind that, you know, not a lot of kids fake and I can tell you
from being a part of the Brain STEPS Program, we've had 100's and 100's and 100's
of lingering concussion cases in the past few years and there have been a handful of students
who were suspected to be faking, that actually were, other than that there really --
it's not something that we run into a lot and we see the worst of the worst cases.
Now if a student experiences lasting symptoms of concussion or mild traumatic brain injury,
which is what MTBI stands for, always remember that a 504 plan or an IEP may be needed
for that student's individual needs.
All schools this year should really be thinking
about a two pronged approach for students after concussion.
The return to play -- all schools already have to think about that, because it was made
into a law, which was in -- which was effective July 1st of 2012.
But we also want you to think about the return to school, the return to real life and we get --
we've been getting asked, is there a general recommended protocol
to help our district manage student concussions?
And the answer is yes, and that's what we're going to talk about right now.
So the Brain STEPS Program, we have a protocol and this is the cover for it and it was
in your handouts that you could've downloaded, it's also at BrainsSTEPS.net,
if you'd like to go there and check it out.
Returning to school after a concussion recommended protocol,
so what I'm going to do right now is I'm going to walk you through a flow chart,
essentially of exactly what the protocol entails.
We thought long and hard about this with the Department of Ed
and how can we make something easy for school districts to do without being a lot of work,
to really build their capacity for the first four weeks
that students are concussed before Brain STEPS involvement?
And this is what we came up with.
So we are creating concussion management teams, and they're called CMT's
and this Concussion Management Teams will either be housed in your district,
so you could one Concussion Management Team for your whole district,
or you could have individual school buildings could each have their own CMT.
That is the preferred method, to have one per building,
and the whole concussion management team is made up of two people,
an Academic Monitor, and a Symptom Monitor.
So we're trying to keep it very clean, very easy.
The concussion Academic Monitor, on the CMT,
will receive a concussion Academic Monitoring tool.
Now this tool is not ready yet, but this is a draft of something that it will look like.
It's going to be one page and it's going to be very easy
and they will use it weekly, with the student's teachers.
The CMT Symptom Monitor will have a symptom severity checklist
that they will interview the student, three to five days per week, it literally takes
like three minutes, to find out how the student is self reporting their symptoms.
So the first week post-concussion, the Concussion Management Team,
once a student have been identified, will share physician instructions provided by the parents,
they will share students symptoms and accommodations for class work
until all symptoms resolve and acutely, again we are concerned that the student is resting.
We're not cognitively taxing the brains, we want to cut all the repetition,
we want to make sure the student's still learning, but yet only focusing on core content
in key concepts for that individual day, once that's mastered, you know,
that's our focus for the student.
The student should be immediately excused from P.E. sports and all physical activity
until cleared and the CMT will notify the athletic department
and coach if the student plays sports.
Now one to four weeks of concussion, the Academic Monitor will monitor academic progress
and behaviors weekly with teachers, using that one page form
and the Symptom Monitor using the other one page form will monitor students three
to five days per week, via student interview.
We've -- get the question a lot, well
who would make a good Academic Monitor and Symptom Monitor?
A good Academic Monitor would -- could be anybody that is in daily contact
or weekly contact with the student, but someone who has easy access to the students teachers.
So school psychologists, counselors, social workers at the school building,
special ed supervisors, those are all great people that could do this, school psychologists,
guidance counselors are probably the top to be Academic Monitors, and the Symptom Monitor --
obviously the school nurse is my number one pick for this, but it could be anybody.
We ask that it not be an athletic trainer, being either of the athletic monitor
or Symptom Monitor, just because a lot of students aren't going to be --
a lot of concussions don't occur during sports.
Only about half I'd say of concussions occur during sports and then the rest occur
from car accidents, falls, assault, different things like that.
Now the concussion management team will monitor the student, they will meet weekly
to review and adjust accommodations.
We have to remember these accommodations initially
for a student, really need to remain fluid.
Accommodations a student is going to need the first week, they are hopefully recovering
and they're not going to need that many accommodations the second week.
So for the sake of the teachers, you know, we want to make sure
if a student doesn't need accommodations, or as many accommodations, that we are tweaking
that plan and making it fit the students recovery.
Also the CMT will offer support in educational resources to the parent and guardian.
Now weekly, basically the concussion management team, these two people will meet together
and they will ask three questions.
They will have -- they will ask how the student's symptoms subsided,
has the student been cleared by a physician to return to full physical and cognitive activity?
And does the -- do teacher weekly reports display no academic or behavior concerns?
And if yes was answered to all three questions, then the student has recovered,
the LEA will formally conclude the accommodations,
the concussion management team monitoring will end, and the concussion should be documented
in the students education file and the student returns to full activity.
If no is answered to any one of these three questions,
the concussion management team continues to monitor the students with concuss --
or the student, until the concussion resolves
or until the student reaches four weeks post-concussion, at that time a referral
to the Brain STEPS Program is warranted.
So once Brain STEPS gets involved,
the concussion management team will make a referral to the Brain STEPS Team.
Now it can occur earlier, if a student has a complex concussion.
A complex concussion constitutes two different things in our mind,
one if a student has prior multiple concussions, we anecdotally know that they are probably going
to take longer to recover and have more severe symptoms.
Also if a student's concussion symptoms are not progressively resolving
within the initial few weeks, you can make a referral earlier.
Now Brain STEPS will offer concussion training to the school staff,
whether it's a general training an individualized student, district team training,
the CMT will set up a meeting to create what's called a Brain STEPS Brain Injury
Now the Concussion Management Team does not need to do this framework,
this is what the Brain STEPS Team comes in and does with the school district.
At this meeting, the school team, the CMT, the Brain STEPS Team and the parent,
guardian and student are invited.
Copies of the monitoring tools, so there's two sheets of paper
that the Concussion Management Team have been monitoring the student with are shared
with Brain STEPS prior to the meeting.
It's really good informational -- informal data that we like to look at.
Brain STEPS, brain injury -- the Brain STEPS Brain Injury Support Framework is created
with input from all parties, we then schedule a follow-up meeting in one month
to review the framework and the Concussion Management Team provides copies of the framework
to relevant staff, parents and guardian and then the CMT continues to monitor the student
like they've done for the four weeks prior.
So four to eight weeks post-concussion for those students who continue
to need ongoing accommodations, again the Academic Monitor
and the Symptom Monitor are going to continue doing --
monitoring the student using their tool, their one page tool each, they will meet weekly,
the two monitors to talk about the students symptoms and the academic progress
to see if anything needs adjusted.
And then -- oh and while they're meeting, the key questions, again,
that they need to ask are those three questions, have the students symptoms subsided,
have they been cleared by the physician to return to full cognitive and physical activity
and does the teacher -- do the teacher weekly reports display no academic
or behavioral concerns.
If they answer yes to all three, then the LEA should formally conclude the accommodations set
forth in the brain injury supports framework, that the Brain STEPS Team helps them create.
The CMT and the Brain STEPS monitoring ends and the concussion is documented
in a student's educational file and the student returns to full activity.
Now if the answer is no to any one of these questions, the Brain STEPS Team members,
the Concussion Management Team and the School Team should continue to monitor symptoms
and accommodate the student until the symptoms resolve.
Now at this point, we're in the four to eight week range now, discussions should take place
as to whether an evaluation should be conducted by the LEA to determine the need
for more formal intensive accommodations and modifications and then if a referral
for a multi-purpose evaluation is not deemed necessary,
then continued monitoring using the Brain Injury Supports Framework
in partnership with Brain STEPS will continue.
Now this is -- I'm just going to show you an example
of this brain injuries supports framework that I talk about that Brain STEPS --
the Brain STEPS program uses, it's really beneficial and we go
through three areas during the framework meeting, so when we come in to help you
with your more difficult cases, we'll go through physical changes,
thinking changes, and behavioral changes.
And we'll talk to the student and we'll --
and the teachers to find out what symptoms are occurring, what time of day,
what class they're occurring in, what exactly the student is doing when the symptoms occur,
what the teachers may be using now as an accommodation
and then we will generate new accommodations that we have seen work, you know,
maybe with other students who have concussion.
And again, it's three different pages that we go through talking about physical changes,
thinking changes and behavioral changes.
This is the list that we go through also talking about what different changes there could be.
[ Background Sounds ]
Now what we just talked about using the flow chart --
or the flow chart that we just discussed, talking about the concussion management teams.
There is another flow chart that is available to you that it describes in more detail,
the protocol, the return to school protocol.
And the hope is that everyone who's on this call today will go back to your district
and discuss the benefits of having your own Concussion Management Team,
either at the district level or at the school building level.
Of course I think it would be easier to have it at the school building level, but we will set it
up however it makes sense for your district.
The benefit of doing this with Brain STEPS in partnership, is that we will ask that you --
after you decide okay yeah we do want to have this Concussion Management Team,
you will then register at BrainSTEPS.net and I'll show you what that looks
like in a minute -- you will register your Concussion Management Team.
And then you will receive notification prior to January
about an upcoming three hour video conference that will be taking place
across the state on January 15th.
The purpose of this training is to train the academic monitor and the symptom monitor
in concussions, and also in their specific role
and how to implement the protocol for your district.
So that's what that training is and also in your handouts today, there's a handout that walks you
through how administrators can register their Concussion Management Teams,
so essentially all you do is you determine you want to have one.
The Concussion Management Team again consists of two people, an Academic Monitor
and a Symptom Monitor, you log into BrainSTEPS.net and there is a link on there
for LEA's to register their CMT's.
By clicking submit, after you fill in the information, the LEA agrees to collaborate
with Brain STEPS for students who do not recover during the initial four week trajectory
or sooner for students who have complex concussions.
Each Concussion Management Team will be registered separately online,
so for instance I know the Allentown School District has 25 school buildings;
they may want to have 25 Concussion Management Teams so they have one per building.
You need to register each one separately,
or you may only have one per district again, that's fine.
And then we will notify you of the upcoming training.
This is our Website, BrainSTEPS.net and right when you log onto the page, the homepage,
you will see this little box right here and that is where your administrators can click
to register their Concussion Management Teams.
And what we will do is once we have our full listing in the next, you know,
by the end of December, we want everyone to be registered and we will then make sure
that your local intermediate unit Brain STEPS Team knows what school districts,
in their region, are agreeing to partner with them to help out
and we'll help you establish your teams.
Now these are just the training objectives for January 15th,
because I know that that's a lot of, you know, a lot of people want
to know what exactly is going to happen on that day.
Now an agreement that that the LEA will make with Brain STEPS is very simple.
Brain STEPS will agree to provide the LEA with an individual student concussion consultation
and in ongoing manner, if a referral to Brain STEPS is warranted,
so if that student hits four weeks and they need help, we are there to help.
Brain STEPS agrees to provide both general
and student specific concussion trainings to school teams.
Brain STEPS agrees to utilize the Brain Injury Support Framework with the School Team, Student,
Family and CMT to assist them in identifying accommodations and modifications
to support each individual student.
And then we can provide ongoing concussion education
to the Concussion Management Teams over the years.
So we won't just leave them hanging, we will instead be working
to build the Concussion Management Teams capacity as research is coming out.
The Brain STEPS Team here -- the Brain STEPS Teams across the state are some
of the first educational people to get this information and we will get it right
out to our Concussion Management Teams.
Now the LEA's, who set up Concussion Management Teams will agree
to notify the students school team, of the concussion,
and insure the student has general concussion academic accommodations put in place
across the settings until their recovered.
They will serve as the communication bridge between all parties involved
in the student's recovery and they will collect student information utilizing the Brain STEPS
Academic Monitoring tool, which is one page,
and the student's symptoms monitoring severity checklist, which is one page.
They will monitor the student info collected from these tools weekly during their CMT meeting
and they will make adjustments to the academic accommodations.
If at four weeks a Brain STEPS referral is warranted, they will be the ones
that make the Brain STEPS referral and again if it's a complex concussion,
they can make the referral earlier.
They also agree to work collaboratively with the Brain STEPS Team in their region.
Now we put together some resources for you, they're all available today,
I hope you were each able to download all of them, but this is the teachers desk reference
on concussion, brand new, hot off the presses, just came out last night,
it's about six pages long and it's excellent.
So we're really happy that the Department of Education has let us publish this as one
of their teacher's desk references and it gives you a lot of information,
a lot of what we talked about today is in this document, so please share it
with parents, students, and your teachers.
This is also one of your documents that you could've downloaded and it is our Return
to School protocol, this takes you step-by-step and shows you the detail of what it will entail
to have a Concussion Management Team.
So it walks you through the full steps of what it takes, and again,
we did this because we once stilled the district capacity to be managed concussions
that get better within the first four weeks.
And it's the students that aren't getting better that -- where we have the questions about,
you know, the student is missing so many months of school or is so far behind,
the parents may be not wanting the student to, you know, have to make up a course,
the school isn't sure what to do, because the students missed so much school
and content builds on each other, you know.
That's where Brain STEPS can really come in and help you through those shades of grey,
because we know that there's no black and white answer to many of these questions,
but we also have experience to help you make decisions based on other cases
that we have been involved in, that have maybe generated the same types of questions.
This is the Brain STEPS flow chart that was also an attachment to really just help you walk
through exactly the step-by-steps.
We tried to make this very easy, so I hope that you find it easy and I hope that you agree
to partner with us to do a Concussion Management Team and if you do,
again these are the instructions that you could download on how
to register your Concussion Management Team at BrainSTEPS.net.
We do want everyone registered by the end of December, so that we can properly plan
and we're encouraging everyone, you know, so if you have friends in other districts
that couldn't attend today's Webinar, this Webinar is going to be archived
and it will be available online in about two weeks or so.
So you could either check with me or check at BrainSTEPS.net
or at Patton.net and it will be there.
Now these are our Brain STEPS flyers that we have, these are produced the Patton Office
in King of Prussia, these are what we use to get the word out about Brain STEPS.
This is one of my favorite quotes "No injury is too severe to despair of,
nor too trivial to ignore", I just wanted to throw that in there to --
now I'm not wrapping up yet, I just have another minute [laughter],
this is my contact information again with our Website BrainSTEPS.net.
There are some fabulous tools available, these are our references, there is some fabulous,
fabulous tools available to all school districts across the United States
through the Centers for Disease Control.
And if you would like to order them they are 100% free,
the Centers for Disease Control will mail them to you; they will ship them out to you,
their tool kits about concussion.
The newest tool kit that they came up with about a year and a half ago --
maybe two years ago is this one, Head's Up to Schools, Know Your Concussion ABC's,
it pertains to school psychologists, school nurses, teachers,
it's just really great, fast information.
So that is something you could order for your school districts,
if you want to place multiple orders through the CBC you need
to call the 800 number on the Website.
So if you're going to order something on the Website,
you can only order one copy of each, so be aware of that.
It doesn't say that anywhere, but you need to call to get multiple copies.
This we give out all the time, you can get for free for any youth coaches, so Pee-Wee's,
Midget's, Pop Warner; this is a fantastic concussion tool kit to give to the coaches.
Because our coaches, our parent coaches really need
to know what a concussion is and how severe it can be.
Now today we didn't talk about a lot of different things, because we're going to touch
on all of that during the January 15th training where we really go in-depth.
But Second Impact Syndrome is something that can occur, it's rare, but it is impetuous,
one of the impetuses, for having the concussion law that was passed in Pennsylvania.
Essentially what Second Impact Syndrome is, is when a student has one concussion,
if they sustain a second concussion before that first concussion is healed,
they could sustain severe disability impacts or even death.
Now again it's rare, it has happened in Pennsylvania a few times, but you know,
I don't want to scare people, but that was one of the main reasons why this law was passed.
What we typically seen -- really occur is that severe disability can ensue if --
what happens is the brain swells faster and does much more damage,
because again it's in that vulnerable state.
So this is why it's so key to get your coaches onboard and if there's a Brain STEPS Team
in your region, the Brain STEPS Teams have helped youth leagues,
we have one team that partnered with one of their Pop Warner, Pee-Wee,
Midget Teams for football and they weren't doing any --
they weren't letting any student play until they had sat through a Brain STEPS training
on concussion with their parents.
I think that's an awesome idea, I don't know how relevant or easy that would be, you know,
to do everywhere but -- for the littler kids, it's very,
very important that they understand the signs of concussion and what we also see happen,
is many students do not -- even though they're aware of concussion symptoms,
they don't always want to self identify.
So this is where we want the peers to be educated
to identify concussions in their friends.
Because if a students playing football and it's Friday night and he comes back after getting hit
and no one really saw him get hit, but he feels jolted and he's feeling a little woozy,
a little dizzy, chances are the grave majority of kids,
if no one comes up to them and says hey are you okay?
They're going to go back out onto that field, and if they're feeling weird
like that, they have a concussion.
They shouldn't be going out on that field, so that's why we want to train students
to identify concussions in their friends.
Because they don't want to let their team down, so we have to use the peers.
Now also, there is a concussion tool kit for pediatricians, school nurses,
it's really great for, it's called "Head's Up, Concussion in Your Practice",
so it's also a great resource and this one is probably the one that's most requested
from the CBC it is "The Tool kit for High School Coaches" it's excellent, it comes with --
well here it shows a VHS tape, but it doesn't come with a VHS tape anymore,
it comes with a DVD and you can actually watch a case study of a student who was playing football
and they show him on the field, he went back to play with a concussion,
sustained a second concussion and is now living with very,
very severe disabilities because of that concussion.
But this is great to get for your high school coaches,
for those of you that are in school districts.
Okay so that is where I'm going to wrap it up for today and if again,
so the point of today was to give you some concrete strategies to help
when student's have concussion, to help you feel a little bit more comfortable,
so you have more information now on how to identify a concussion
and how to really start implementing concussion accommodations that are based on research.
And the research is that we know that total physical
in cognitive rest initially is very important, now three months from the point of concussion,
we're still really waiting on any research to come out saying
that total rest is important at that point.
It's kind of like a broken leg, when you have a broken leg you need total rest for that leg
to start healing acutely, but then once you're a few weeks down the road,
you don't want to remain on total rest, so once the cast -- maybe a few months --
once the cast comes off, you need to go to physical therapy and start moving that,
so it's kind of like the same thing with a concussion, acutely we want them on total rest
for the first few days, maybe up to a week.
Then they come back to school gradually with accommodations in place,
with the supports in place that we're offering, and then over time we can pull back
on the supports and hopefully the student will be recovered.
The whole point in this is that we want students to recover as fast as they can and the way we do
that is by letting their brain rest while keeping them in school,
so it's up to us as the adults to make sure that we have a plan in place, to make accommodations
for the students so we aren't cognitively fatiguing them.
So talk with your districts, register your Concussion Management Teams at BrainSTEPS.net,
we will fully support them and we look forward to having a wonderful partnership with all
of our districts across Pennsylvania through the Brain STEPS Program in the coming months.
So thank you very much and if you have any questions at all,
feel free to send me an e-mail or give me a call, thank you.