>> Good afternoon, everyone.
Thank you so much for tuning in today for the first in our Return
to Learn Fall 2014 BrainSTEPS Concussion Webinar Series.
This series was created to assist educators and related professionals
working in the school setting to help build educator capacity,
to appropriately for and manage students with concussions,
until those students have recovered.
The webinar series this Fall was created by the BrainSTEPS Program.
BrainSTEPS was created in 2007 by the Pennsylvania Department of Health
and is jointly funded by the Pennsylvania Department
of Health and the Pennsylvania Department of Education, Bureau of Special Education,
via the PaTTAN Network.
BrainSTEPS is implemented by the Brain Injury Association of Pennsylvania.
The webinars in this concussion series were created to build the capacity
of teachers working with students who returned to the classroom
after a concussion.
This series does not replace the official Pennsylvania BrainSTEPS Return
to Learn Concusssion Management Team Training.
Attendance during this webinar
does not denote TMT formation or BrainSTEPS Team membership.
This webinar is for educational purposes only.
If your Pennsylvania school district is interested in forming
a concussion management team for academic and symptom management, please
register your TMT at www.brainsteps.net,
and then an online training information email will be sent to you.
We hope that your school district has already joined the over 700 Return
to Learn Concussion Management teams
that have formed in Pennsylvania within the past one and a half years.
But if not, please
talk with your supervisors about establishing a team.
When you form a Concussion Management Team through the BrainSTEPS program,
you will receive training in returning to learn for students
following concussions and how to manage these students for the initial four weeks
Your Concussion Management Team
will also receive a Return to Learn Concussion Electronic Toolkit,
that includes things such as an academic monitoring tool,
a symptom monitoring tool,
a parent concussion letter,
and individualized teacher weekly accommodation letters,
among other tools.
You will also receive ongoing support
and networking from your local Intermediate Unit BrainSTEPS Team
and you can receive ongoing information
and training through the Return to Learn Concussion Management Team website.
And it is also free to form and train a Concussion Management Team
in Pennsylvania.
Pennsylvania is unique in that we have a layered statewide infrastructure
for supporting return to learn following concussion.
What happens is after a student has a concussion,
has a Concussion Management Team in place at the school district level,
by implementing academic adjustments and accommodations
as the first layer of support.
If at four weeks a student is not recovered from their concussion,
that is when you can make a formal referral
to the Intermediate Unit BrainSTEPS Team
in your region
and then we step in and help provide more individualized consultation,
training, and educational support
to those at school, the family,
and the student.
And just as a reminder for those of you who may not know,
your Intermediate Unit BrainSTEPS teams,
there are 31 across the state of Pennsylvania.
We do have BrainSTEPS teams in every intermediate unit in the state
as of the beginning of October,
and we will work with any student
Now for concussions,
we ask that you wait at least four weeks post-concussion to make a referral,
because the majority of students will recover within that timeframe.
If a student has had prior concussions,
if they have a history of migraines,
or other learning, attentional,
or emotional issues in the past,
then they may have a more protracted recovery
and you can go ahead and refer them to the BrainSTEPS program
earlier if you would like the assistance earlier.
but have more moderate traumatic brain injuries,
severe traumatic brain injuries,
or have non-traumatic brain injuries,
such as stroke, tumors, aneurisms,
near-drowning, lightning strikes,
anything like that -- and also,
these students can be referred to the BrainSTEPS program
also for consultation and training
that can be provided to your school district team.
is in the BrainSTEPS School
Reentry Program title,
we will work with students not just with brand new brain injuries,
but students that have injuries that occurred in the past
to their brain that may be impacting their education now.
And this is just a reminder,
we hope that you have registered for all of our six Return
to Learn Concussion Webinar series this Fall.
If not, please do so using the pattan.net
email address -- or, excuse me -- website below.
For this webinar, we ask that no questions be asked during the webinar.
Instead, we ask that if you have any questions
that you email them to me at this email address.
Dr. Gioia will then answer them and we will post them online.
The webinar from today will be archived and available online in about a month.
will be posted online and available with the archived version.
You will be able to access the webinars at both pattan.net
and BrainSTEPS.net in about a month after each webinar takes place.
Now I would like to introduce Dr. Jerry Gioia.
Dr. Gioia is a Pediatric Neuropsychologist and Chief
of the Division of Pediatric Neuropsychology.
where he directs the SCORE Concussion Program.
He is Professor of Pediatrics and Psychiatry
at the George Washington University School of Medicine.
Dr. Gioia is a clinician, researcher, teacher, and trainer.
He has been the PI of several multi-site TBC-funded research studies
of pediatric mild traumatic brain injury,
developing new tools to evaluate post-concussion functioning.
He has worked with the CDC
on their Heads-up Concussion Educational Toolkit for Health Care Professionals,
Parents, Children, Coaches,
and School Personnel.
Dr. Gioia has participated in the 2004, 2008,
and 2012 International Concussion
and Sports Group Consensus meetings,
the American Academy of Neurology Sports Concussion Guideline author pannel,
for Mild Traumatic Brain Injury.
He works with the Washington Capitals of the National Hockey League
and Baltimore Ravens of the National Football League.
He also consults with youth sports of ice hockey, lacrosse, football, rugby,
and soccer.
He is a member of the Medical Advisory Committee
for US-based Football,
National Advisory Board of the Positive Coaching Alliance,
Advisory Council of the Former US Surgeon General,
and is the National League for Mild Traumatic Brain Injury
for the Pediatric Acquired Brain Injury Plan.
He is the father of three children whom are now young adults,
all of whom were active in various youth sports,
and is also a new grandfather.
With that, Dr. Gioia --
>> Well, thank you, Brenda.
Thank you very much and I really appreciate the opportunity to be here.
Just make sure that my slides are --
are they showing now?
>> Yes. >> Great, super.
So thank you again for inviting to speak
and I am really pleased to talk about an issue
that is near and dear to my heart,
which is basically how do we get kids back to school
as soon as we can and also as effectively as we can.
that we really want to address in some depth this afternoon.
and what underlies it.
but we will talk about what happens to the brain
understand why we would then try to treat it in certain ways.
that they play out functionally or dysfunctionally for the student,
and then talk about a more active model of individualized treatment --
possibly more active than what we have heard in the past.
Then also for those kids that are going to take longer to recover,
of which there is a certain percentage,
what are the kinds of therapies and interventions
that we can put in place,
but to do so,
you know, based on what the needs of those students are.
and so I have spent my time in the schools,
working directly with kids, with families, with teachers, with administrators,
and so although I worked in the hospitals now for the last number of years,
I am very interested in how we can return kids back effectively
to the school setting.
So I think one of the things that we need to be --
we need to think about --
is that tomorrow morning at any school around the country,
certainly in Pennsylvania,
if a student is identified with a mild traumatic brain injury or concussion --
What should be the response?
And I would also pose the same question to the medical professionals,
saying what are you going to do to understand that youngster
in helping them get back to school,
and what is that partnership or interaction and collaboration
with the school and with the family to make that happen?
Now I will tell you that we oftentimes in these past number of years
have thought about concussions largely in terms of the sports,
and I can tell you that the majority of injuries
that result in a mild traumatic brain injury are not because of sports.
Probably only 30, 35 percent are sports and recreation-related.
Here, this could happen on your school grounds.
A student is playing on the playground at recess,
he or she falls on the playground equipment,
and lands on his or her shoulder and head, does not get up --
He or she then comes over to you initially a bit groggy and appears stunned.
After a few minutes,
he or she seems to look okay and wants to go back to play.
encouraging him or her to come back to play.
So as the responsible person in that school setting, what do you do?
Am I prepared -- is my school prepared?
Do we have the team in place to address this need and this issue?
all that strongly the fact that,
learning new information,
as is practicing that incompletely learned knowledge.
Some of us might refer to this as classwork or homework,
but those are two very important skillsets.
to do things that ask a lot of the brain.
What we know though is that when that brain is impaired,
it can affect that process.
And so some of the questions that I think again
a school needs to ask and be prepared
for are when a student is identified with a concussion,
what is your response,
and what is the response at all levels:
high school, middle school,
elementary school.
And who makes up that team?
Who is going to do what?
What will be their roles, responsibilities?
Who is in contact with the parent
and who is going to be the one connecting the teachers, the teaching team,
And ultimately what will be that method
of supports or accommodation strategies that they may need.
and certainly as seen through the model program of BrainSTEPS,
really will focus on this issue to support kids.
And then what is the program for preparing our teachers
to then manage these issues in their classrooms
to understand the effects of concussion?
A couple of other questions,
and this also would be one that might be posed to the medical profession,
when does a student stay home and when does a student return to school?
What are the criteria for them returning and do they return partially
or a full day?
And what information do you base your decisions on?
And then again, where,
how and who will provide the key supports for that student?
And once in school, how are you going to monitor the moving target of recovery?
The good news is these kids get better;
students definitely improve.
and monitoring their --
their progress toward recovery
and adapting the accommodations as that student then presents.
So the goals of --
of a proper school return
would be really to prepare both the medical and the school system
to work together,
where that initial medical evaluation of the student
is conducted by the healthcare provider,
and that is then communicated to the school.
There is coordination and communication between the family,
the medical provider, the school,
with the athletic administrators,
coaches, teammates,
We want for the school team
that is defined in a variety of ways, not just the teacher,
into the kinds of adjustments and accommodations
that is going to help that youngster really achieve two goals:
recover,
become healthy, as well as learn to the extent
that they can.
And then of course as we say, monitoring in an ongoing way that progress
and communicating that to the medical provider
who may have some additional input, based on that updating,
as well as the family who of course
largely in the media.
So what is it here?
A concussion is basically a force that is applied to the head
when a bump, a blow,
or a jolt hits the head or hits the body such that it causes the head
and the brain to move back and forth rapidly.
It causes a stretching and a straining of brain tissue
and causes chemical changes to that brain
and can have some effects then on the cell --
some temporary damaging effects
to the cell.
What that does then is it causes that -- that brain --
to change how it works,
Now once this brain has actually been affected in this way,
the brain now becomes more vulnerable to further injury
and very sensitive to increased stress.
because we want to be sure that number one,
and number two,
we want to know how to manage the stress
and that will ultimately be the job of the school team,
the family, the student will work together to make that happen.
So again, as I mentioned before,
So here are the kinds of things that you might see following that blow to the head.
These are the signs or what you observe.
Cognitively, that youngster may appear stunned,
dazed, confused about things,
answering the person much more slowly than normal.
They may even be repeating questions, asking the same thing over and over again
or forgetting what they were just told and asking to repeat.
And they may not have a good running memory
of what events occurred before the injury or just after the injury.
Physically, they may vomit, they may lose consciousness,
they may have balance problems and be quite clumsy in their movements,
and they may appear very drowsy.
And their behavior and emotion may change.
You may see that a rather stoic individual becomes more disinhibited
and is crying very easily,
or you may see somebody who is typically a happy-go-lucky person
now really becomes sullen.
Now, you look at those signs and you might say,
And so when we think
about concussion,
to the head followed by the signs of --
to talk about in, you know,
reasonably close proximity of time.
So now the symptoms are what a youngster would report to you,
And here we have the headache --
that happens, you know, about 80 plus percent of the time,
again, a tiring, fatigue affect, blurry or double-vision, again,
a kind of nausea --
feeling kind of sick to your stomach --
feeling off balance or dizzy,
and then being very sensitive to light and noise.
And in some cases, usually when there is more of a neck strain,
we may see numbness and tingling.
Sleep can be affected because that regulatory system
is not getting the same inputs it normally does,
and so you might have somebody
Or they might be sleeping less and oftentimes
And again, they may be more drowsy.
Now cognitively, what we may see is that there is more of a fogginess
or a kind of a lack of clear thinking and difficulty
concentrating, maybe even troubles
remembering and being more slowed in your ability to think.
And then emotionally,
we really know kids can really be affected in that they are more emotional
and they have troubles controlling that emotional response --
much more irritable, sad, nervous.
that we may see in other conditions as well.
in close proximity or temporal proximity to the blow.
So one of the other things that would very helpful of course
is for us to understand how long does it take for kids to recover?
What we know is that our research literature,
particularly with -- with children across the full age range,
as well as for both boys and girls, is still pretty limited.
And so that affects our ability to truly know or predict
the recovery timing of --
of any individual.
And the Institute of Medicine report in 2013
highlighted this problem with our --
our knowledge of the incidence of the problem.
There at times is this expectation
that kids are going to recover between seven to ten days,
and whereas that certainly may be quite true for some kids,
and so we have to be careful about that.
Each one of these -- these injuries has its own individual recovery trajectory
and we believe that perhaps that 80 to 90 percent
are recovered within one to three weeks.
But that also means that you have a more prolonged recovery
now approaching a month
for ten to twenty percent of --
of the population.
that is elementary and middle school children,
even at the high school level,
so we have to be a bit careful about overgeneralizing.
each concussion can be its own thing.
We oftentimes say that concussions are like snowflakes;
each one has its own individual characteristics.
What we see here is we have the brain inside the skull
and it has a kind of white, which is fluid surrounding it.
And when that blow occurs,
what we see is that brain moving back and forth and having some independence
in its movement inside that fluid.
And what we see is -- is that the brain hits up against the skull --
I want to show you another way that --
that the brain has moved,
and this was provided by my good colleague,
Joel Spitzel,
a biomechanical engineer at Wake Forest School of Medicine.
And in this one, what he does is he shows us how the brain actually moves
and rotates in varying ways when it takes these forces,
and so you see the stretching and the straining.
because that brain sits on the brain stem
and may move at different rates at different times.
And so the str-- stretching and straining,
what it does is it releases chemicals in the brain,
such that Calcium comes into the cells at abnormal rates
and when we look at this graph,
we see 100 --
with a pen here --
how the line here,
the 100 line,
is basically the normal degree of chemical concentration.
And what we see with our Calcium right
here is that it has really become abnormal over this period of time,
and you can see that it goes from minutes, to hours,
to days where you have that abnormality.
So Calcium coming into the cell at an abnormal amount.
Potassium here, the K plus, is coming out of the cell abnormally.
As you can see, it kind of comes up off the line,
but over time, we actually see less glucose
into the brain has reduced.
And then we see things like our neurotransmitters
at an abnormal rate.
So the bottom line here is that this is a process --
a chemical process -- of abnormality
that we then --
that the brain has to deal with.
We think about these effects
largely as being ones of impairments of the software system,
the electrochemical system of the brain.
Lesser is hardware.
as there is that impairment in the --
the chemical concentrations
and the electrical conduction.
And so the relevance of this clinically to a youngster, again,
that acceleration, deceleration producing the stretch and strain,
again this being more of a software injury
versus a hardware injury,
where we believe now that those software changes,
the chemical changes, the conduction,
actually normalize and recover over time.
Whereas we know that hardware injury where tissue is being torn,
does not recover.
that goes on where the brain does not have the same capacity either
to generate energy or to conserve it.
that energy available.
There is an important relationship between the energy
you have available and using too much,
may also have some adverse effects.
or also not doing too much.
we want the medical provider to be able to do the initial evaluation
to really identify the symptom profile for that student,
to communicate that obviously to the family,
but then also to make sure that information
is being delivered to the prepared and trained school team
so that they can then put systems in place.
We developed back in 2006 something called the Acute Concussion Evaluation.
That is a tool for the medical professionals
to help to evaluate youngsters.
The ACE,
or the Acute Concussion Evaluation, helps the --
the medical practitioner to describe the injury,
to talk about what the cause was,
and then to look at whether or not a number
of different injury characteristics occurred,
such as not having memory for information before the event happened,
what we call retrograde amnesia,
or not being able to form new memories after the injury,
something we call anterograde amnesia.
Was there a loss of consciousness or not?
What we know is that typically, the minority of kids lose consciousness --
maybe ten percent or so lose consciousness.
And then what were some of the early signs that somebody observed, again,
based on confusion, answering questions slowly,
repeats questions, being forgetful.
In a very small number of cases,
a youngster may actually have a seizure or those observed or not,
so this gives the medical practitioner
a way to standardly gather key information.
And then what we do is we look at --
we ask the youngster, what symptoms are you manifesting here?
The physical symptoms, the cognitive symptoms that come along,
we can actually highlight those, the emotional symptoms
that may be coming along, as well as whether sleep has been impaired.
We can get a total score here.
that is, to what extent does physical or cognitive activity worsen symptoms?
And then an overall rating --
how different is this youngster
from how they normally act or behave or think or sleep?
The practitioner also wants to know whether there might be certain kinds
of factors here that tell us
that this youngster may be more at risk for a prolonged recovery.
if you have your own history of headache or a family history of headache,
or if you have a developmental history of learning disabilities, ADHD,
it seems to take longer for you to recover from this injury.
of those individuals, as well as a psychiatric history
of anxiety, depression,
a sleep disorder.
So these are all things we want to know because we want to be prepared,
we certainly want to anticipate whether a youngster
may have a more typical recovery within that one to three week period,
or longer.
and these are things that physicians as well as the family need to be aware of,
because any one of these red flags
would suggest that youngster
needs to be sent to the Emergency Department right away.
the ACE, the Acute Concussion Evaluation,
what we call the Heads-up Brain Injury in your Practice Toolkit.
That was published in 2007,
and over the next few years we worked on the school toolkit
and here we have a Concussion Signs and Symptoms Checklist,
which a school health professional can have, be it a nurse, a health aide,
possibly a school psychologist --
someone who has been trained to look for these signs and symptoms.
Again, possibly as a tracking mechanism,
or in the case of our initial scenario,
an injury that occurs in school,
we look at the physical symptoms,
we can track them again over --
over time, the cognitive symptoms, the emotional symptoms.
Danger signs, these are those things again,
particularly if the injury happens at school we want to be looking for.
I can tell you that these danger signs become less relevant
because they are really signs of either a bleed
or swelling in the brain or something more acutely that is going to present.
And so once the student has gone 24 to 36 hours after the injury,
the likelihood of this occurring is very remote.
We can then look at how these -- these effects --
so we see that there are various kinds of post-concussion effects here
We see that attention and concentration can be a problem.
The ability to hold information and working memory, or short-term memory,
the ability to -- to consolidate or retrieve new information,
or to do it in a quick way.
When we look at these neuropsychological functions right here,
we can translate them into how they play out,
in terms of the school problem.
Difficulty focusing on the lecture, the classwork or the homework,
or holding, you know, the lecture in mind or holding the information
Again, the memory kind of consolidation and retrieval,
difficulty now retaining new information.
and I cannot remember who that person was that you said discovered America
or that did something important --
difficulty for that brain to kind of put new information in there.
Or doing it in a way that allows you to keep pace with, you know,
We also can then look at the varying kinds of symptoms here that can play out,
and so here, headaches, again, very common.
That obviously can disrupt your concentration, your ability to learn,
and to remember, as well as to just manage the activity --
the stimulation in the environment.
These are symptoms that in a bright classroom
or with artificial lighting
can be a real challenge for kids --
or in a noisy cafeteria or hallway can --
can really effect how the youngster feels.
So we need to think about, you know,
what we might ultimately be doing to support them if they have that kind
of a symptom profile.
We can then look at accommodation and management strategies.
because I know that Brenda is going to do this I believe in her talk next time
talking about the management strategies.
But I can tell you that we linked together the type of post-concussion effect,
the way it might play out functioning in school,
with a certain kind of accommodation and management strategy.
This table, by the way,
comes from an article that I have sent on as a handout
that you can have and you use this table with it.
that do similar kinds of things,
but this one looks at the actual effect of the symptom on school
and what you do about it.
We also can look at, again, dizziness and balance
and how that may play out in terms of somebody ambulating through the school,
or again, what sleep disturbance might do,
things -- emotional issues like anxiety and how that obviously interferes
with concentration or how the student, you know,
We oftentimes see kids can be pretty down about this injury,
either directly because of the brain injury
or because of the restrictions on them,
and then we see some withdrawal.
which is one of the symptoms worsened during activity.
And again, a variety of accommodation strategies you could put in place.
So think about again,
that youngster comes to school tomorrow whose been identified with an injury,
has been defined in terms of their symptom profile,
You can look at a table like this
We can start to mobilize a plan
And those -- that kind of information
is available on the CDC website,
Heads-up to Schools, Know Your Concussion ABCs,
and you could see the website here is cdc.gov/concussion.
So lots of good information;
all of its downloadable for you.
You can really bring these into your school
and have this available for your use.
An additional tool, this is something that I also included in the handout --
this stack of handouts that were provided --
is this 12-page Returning to School
After Concussion Fact Sheet for School Professionals,
and what it does is it addresses each of these different problems,
or questions really,
So, what role do you play?
You know, what kinds of accommodations do you put in place?
What are some strategies?
And what kind of formal supports
might be available for a youngster with persisting symptoms?
This is a really good handout.
this is a great one.
This is the paper that I mentioned that that table comes from,
the School and the Concussed Youth:
Recommendations for Concussion Education and Management,
and this is our colleague, Megan Sady,
that worked with us on this paper.
of how this injury can play out in the school environment.
But I also want to alert you to the fact
that the school environment and affect the recovery as well,
and so we really have two issues to address here.
So when we look at how these play out,
one of the CDC handouts actually goes through
and talks about the various kinds of behavioral, cognitive,
emotional manifestations that we see in school,
and so paying attention, remembering,
more of your ability to organizing, fatigue, headaches worsening.
I can tell you that we actually did a study where we looked at kids in --
across the three grade levels,
so we have elementary,
we have middle school,
and we have high school students.
And we asked -- these are kids all that came into our clinic
with concussions --
and we wanted to know how concerned
are you about your concussion affecting your school learning and performance.
And the students -- well basically, this table shows that, you know,
in the elementary grades,
32 percent were not concerned.
And what you see is a --
a pattern where kids are increasing in their level of concern
as the school complexity and demand goes up.
And a similar kind of process with parents,
than the students are,
in terms of the percentage of concern.
And what we see with this then, as I say,
is that there is basically a pattern
where as you move up in school level, the concerns continue.
Then when we look at the types of problems that kids are reporting,
we see headaches interfering and how at the high school level,
almost two-thirds of the kids are reporting this.
difficulty studying for tests,
and so again,
what we see is a relative increase in the reporting of these problems
as you move up in grade level.
We have two on average, a little fewer than two at the elementary level,
a little fewer than three at the middle school level,
a little fewer --
a little more than three --
at the high school level.
So it seems like the school demands are being --
as they move up.
These are the kind of classes that the kids report having challenges with,
and I want to just sort of highlight a couple of facts here.
What we see actually is that Math,
and I sort of highlight the student here,
we also asked the parent to what extent they understood it.
30 percent of the parents said,
whereas there was 13 percent students had said that issue.
But what you can see
We see that that goes down, again, depending on your level of schooling.
and about a third of them in Social Studies and Foreign Languages.
So the point here is that we need to be aware that these issues
for a concussion can
manifest in different ways,
depending on your level of schooling,
probably the nature of your injury --
this all plays ultimately toward individualized management.
And again, here the greatest concerns the kids reported,
So the point here is that there are challenges that we need to address.
We asked kids, you know,
to what extent did your symptoms worsen during physical and cognitive demands,
Again, a little bit higher in the middle and 62 and a half percent
at the high school level said that over that last week to two,
their symptoms got worse during cognitive activities.
You see that it is much lower as it relates to physical activities
in the physical activities a bit more effectively,
whereas they need to be in school.
Kids were reporting that they have little opportunity
to not engage in cognitive activity at school,
so the simple message here is we need to do something to support them.
So let me address another important issue here with concussion,
which are the psychosocial issues.
These are things that oftentimes can be hidden from our --
our immediate presence,
Number one, this is an invisible injury and oftentimes
that internal traumatic brain injury is not appreciated.
These kids generally look normal,
and in fact, they want to look normal.
They are cut off from their social group that might be their team,
that might be their friends
or they might not be able to take part in the cafeteria activities.
those restrictions.
And also again, feeling the pressure to be normal,
to return back to what they typically do to contribute,
doing that because they are symptomatic
and they cannot engage in all of the activities.
And then just the pressure of the mounting schoolwork,
that are very stressful.
We also know that if you --
if you have a preexisting problem with anxiety or mood,
that can just accentuate these issues more so.
their ability to cope with an injured family member,
and their capacity to support --
we have a lot of families that are two working families
but just are not available to do that.
and make sure that there is the best understanding,
the best capacity for support.
to what extent do they understand this injury,
identify the needs of the youngster,
and put those supports in place,
All those things are critical factors
I also want to talk about the relationship of emotion,
the energy deficit of injury,
and recovery.
and possibly an under-appreciated and under-studied area.
We know that obviously emotion is very critical to motivating behavior
or social interaction or cognitive performance.
And we get excited about things;
it motivates us to do things,
or we get fearful about things and sort
That emotional activation requires energy.
There are been good studies that have been done that show the amount
of glucose utilization under emotionally charged situations,
including stress.
So stress, anxiety,
and disorders of mood actually demand pretty significant energy.
They actually can drain to some extent energy from that student.
that either facilitates or adversely affects recovery.
So again, as we go back when we think about the energy crisis
of concussion where the mitochondria,
which is the power plant in that cell cannot generate that energy as effectively
that is not helping recovery.
That is not helping them to function effectively.
about what the cognitive demands are on kids in school
and what the physical demands are on kids in school,
but also that emotional demand.
What is our management or our treatment of this, right?
that likely manifests in certain ways in their school functioning
because of cognitive, physical, emotional kinds of challenges.
How are we going to help them? What are we going to do?
Number one, one size does not fit all.
each snowflake has its own uniqueness, so why would one treatment method fit all?
and that individualization is based on a good symptom assessment
and a good profiling of what that youngster needs,
what kinds of supports and accommodations we put in place.
And this is again the reason why the medical system
needs to communicate with the school and the family
and they need to work together so
so we could put the right things in place.
Some assumptions here are that when symptoms
worsen following physical, cognitive --
we could even say emotional activity --
as those symptoms worsen that the brain --
its -- its underlying software,
is being pushed beyond its limits.
So we -- we think about how we want to manage this in such a way
that through recovery, we --
we do not allow that neurometabolic system to be overwhelmed,
that threshold to be exceeded.
that worsens symptoms significantly.
that can result in more prolonged symptoms are ongoing headaches.
As I said, the fatigue,
challenges where you cannot maintain the same energy
and so that cognitive activity results in you really draining more easily.
or balance is off.
That is a common kind of culprit in kids.
And then the cognitive problems,
the range of challenges attentionally and in learning information
and committing it to the memory, as well as again,
the executive functions,
which are those control systems of our thinking and our behavior,
as well as speeded processing.
And then finally, somebody who has that anxiety and mood problem
that again, is --
is kind of revving that symptom -- system --
and not allowing that recovery to occur,
So the issue here then is --
is being aware of these common kinds of symptoms that can be prolonged.
When we look at the types of treatment,
I can tell you that right now this is a very understudied area.
We can see that there have been two studies
that have looked at educating the family,
being able to teach them about the symptoms, again,
teach them about the way to manage activity.
There have been --
I have three studies in parentheses
that are looking at approaches of general symptom management,
how we exert in such a way
that we may overdo it or underdo it.
how we actively rehabilitate someone through physical activity.
But there have been no studies to date
that have looked at how we manage the graduated return to school
in an effective way, and of course,
for those of us who are listening who work in the schools every day,
and again, address that very question I posed at the beginning:
When concussion occurs, what do you do?
around this management of graduated return to school.
There are the variety of treatment modalities that are available,
particularly for these symptoms that are persistent.
We could give out behavioral medicine,
teaching kids about how to manage their lifestyle
to reduce their headaches, medications,
the cognitive problems,
various kinds of strategies they can use,
things that oftentimes will work with kids with learning disabilities
or attention deficit,
or how we can accommodate or adjust the environment.
And in some cases, we use medication,
and the same for anxiety and mood;
how do we help through therapy to sort of alter those --
those thoughts or those mood states
that allow a person to function more effectively?
And then the sleep issue can be a traumatic one.
It can be a real issue when somebody is recovering.
What do we do to help someone maintain --
or establish and maintain --
the appropriate sleep patterns that allows them to really energize
or sort of recharge that brain every night.
We think about behavioral sleep treatments and various medications.
And then for the kids whose vestibular systems are impaired,
we think about again,
vestibular therapy that directly tries to rehabilitate that deficit area.
We have some a relatively new approach
that I want to talk about for general management of concussion
And I think this applies very, very directly to someone returning to school.
Of course, the first thing we want to be sure of is
that there are no additional forces to the head or brain.
As we said before, the brain is in a vulnerable state after an injury
and so we want to be sure that it does not take an additional force,
because that can produce a much more significant problem.
We think about the initial period of resting the brain;
But then we move into a more individualized, monitored,
and moderated plan
where we manage symptoms around activities.
How do we find that activity sweet spot?
How do we optimize your activity without overexerting
and creating increased symptoms?
How do we apply the principle of not too much but not too little?
How do we do that with a plan of graduated physical and cognitive activation?
And remember, there are three ways that we could overexert.
Now historically, our approach to concussion treatment
or rest and time,
and this is what we had been saying for many years:
just sort of take it easy,
and there clearly is a role for that.
Certainly, in those first several days, maybe in the first week,
we want to be relatively less active as particularly those acute symptoms
need to resolve.
Here is the statement from the Concussion and Sport Group,
where we talk about the cornerstone of management
being physical and cognitive rest until acute symptoms resolve
and then a graded program of exertion.
This is for return to sport
but what we believe is that a gradual return,
as you see down at the bottom, a sensible approach
involves the gradual return to school and social activities
in a manner that does not result in significant exacerbation of symptoms.
One of the papers that went along with this at the Zurich conference
was one that was written by Katherine Schneider, Grant, Iverson,
and Group here,
where they looked at what is the evidence behind how much rest one should engage in.
And here they conclude that an initial period of rest may be of benefit,
though that there is likely the need to do something else.
So this is another paper that my good colleague, Grant Iverson
and his colleague, Noah Silverberg wrote,
that too much rest may be a problem.
We know that there is evidence that in other kinds of health conditions,
can actually be worsened by too much inactivity.
So it suggests, you know, based on the evidence and this paper
is a pretty good one in the Journal of Head Trauma Rehabilitation,
that we want to think about whether we go beyond three days of rest in most cases.
We want to instead think about gradually
resuming activities as soon as they can be tolerated.
and how that may actually benefit those who take more time to recover.
So is rest the best medicine?
Again, there actually is little agreement -- in fact,
little study -- on how much that is.
I mean, how long should that be?
and those are two very different concepts.
what the potential adverse effects are of being sedentary,
because there is some evidence that if you do that for too long,
that can create other kinds of problems.
So in Chronic Fatigue Syndrome,
we think that rest is actually something that contributes to the problem
and it may also contribute to maintaining chronic pain.
increasing the susceptibility to depression,
or also potentially increasing anxiety
and other more significant emotional responses --
fears, exacerbating symptoms.
When we look at this issue of bed rest in healthy persons,
we see that after three days of a healthy person being in bed,
they start to develop a variety of symptoms that --
actually, headache, restlessness,
difficulty sleeping, mood changes,
vestibular sensitivity --
these are the very things that we see in concussion.
And so it would be very difficult to distinguish between those.
what should we be doing?
all about really balancing the activity-rest relationship here
and managing symptoms and really managing exertional effects.
which is exertion and the effects that it can produce,
and how we want teach kids to exert in a moderate way
So exertion is basically defined in the dictionary
and I would argue that metal is both cognitive and physical.
But the reality here is that activity and rest really sit along a continuum
and there is really no such thing as total rest.
you know, dead, you know, or --
So what do we care about this?
Because again, we think that those exertional effects
which are the exacerbational effects of activities may be a signal
that the brain is kind of -- this --
its neurometabolism
is being pushed beyond its limits.
And again, that sensitivity to that sense of exacerbation we believe
may be an indicator of where you are in your injury,
and therefore, we might be able to do something about it through treatment.
that we do in our program here
and just about to submit a paper
that talks about some of the --
the metrics of this tool,
which is that before a cognitive activity, we have a youngster rate their headache,
and then after the activity, their headaches,
and we can look at that change and that effect.
We can look at their fatigue in the same way,
we can look at any challenges with concentration in the same way,
and we can do the same thing with their emotional response or irritability.
Index Difference Score.
In this case,
they increased by 12 points across the four.
and also 13 and 18.
And what we see first of all is this blue oval shows kids who are uninjured.
These are normal kids that we have --
we have done cognitive tasks,
concentration, and irritability change.
And what we see is very little change from pre-testing to post-testing.
What we see after the injury though are some differences
First of all, the slope of change
is increased in all ages, in all the groups here,
relative to the -- the kids without injuries.
are very different after the injury,
and particularly teenage girls have the most pronounced effects here.
and what we see here is that --
So what we have is an uninjured group right here and basically,
their average score is a half a point
different across all of those four symptoms between pre- and post-.
What we see with kids within a couple weeks of their injury
is a much higher score.
they actually get better over time
But I can tell you that this is about two weeks,
this is about four weeks,
this is about six weeks.
So that is a significant amount of time spent in school where your symptoms
So again, this might be a tool
that we can use to help us to help kids recover over time.
So we use this not too little, not too much principle.
There actually was a study that looked at this
when they reviewed a group of charts.
This is the Pittsburgh group that showed that kids
that seem to have done not a lot of activity during their recovery,
and those kids that did too much activity --
the highest levels of activity --
both had challenges in their recovery process,
relative to the kids that did more of a moderate level of activity,
When we are teaching kids and families to manage their -- their recovery,
we use this program we call the PACE Program --
Progressive Activities of Controlled Exertion.
So in other words, what is it we can do that can help you control the amount
And these are the four dimensions
we look at which is setting a positive outlook on their recovery,
defining what kind of schedule they have during the day for activity
and what kind of exertion that produces,
teaching them again active exertion monitoring, and management
and then reinforcing their progress over time.
So this is a way that we could give kids tools
and again, ideally inform the Concussion Management Team
as to that toolset
because I think this becomes a really important issue
as we are thinking about those first few days
and then how we progress somebody
over time back to health and back to full academics.
But the idea here is that we are going
to gradually increase the demands, the activity,
as a youngster is improving,
and we have some criteria that can move them from a lower level of activity,
back to a higher level of activity.
So when we think about this.
At first, I oftentimes say to families,
keep your child home one, maybe two days,
We can then look at returning them to school --
possibly a partial day,
then move to a full day with lots of supports built in throughout the day,
in response to them getting better,
and monitoring them as they get to final recovery.
So if we look at that,
what are the kinds of activities we might want to expect?
is to maintain a relatively low level of cognitive and physical activity.
That does mean people typically have to be in dark rooms;
it just means they need to monitor their symptoms
and do things that do not worsen their symptoms.
Oftentimes, that means not too much prolonged concentration.
You know, they can talk with their mom and dad and their friends,
they can maybe do some light activities,
maybe a light game or something,
that really depends on what their symptoms are about.
As you see the youngster improving,
we can then do a little bit of a challenge task
a relatively easy Math or reading challenge task
for up to 30 minutes.
And we assess them -- can they handle it?
Maybe the kids can handle that, so now we want to think, you know,
do we send them back to school part-time,
or in cases of some kids,
they can go back full-time within that day or two.
that allows that brain to recharge during the energy crisis state.
We would not have many expectations for tests or homework,
minimal expectations for productivity,
with our building in rest breaks throughout the day, two to three.
Some kids might need three to four.
Again, minimal expectations for productivity and homework.
some small kinds of things like quizzes, homework starts to build up.
and you can begin to design that schedule for make-up work
if that is part of the picture here.
Again, now that you have a youngster
they begin to just have a modified schedule of testing and of homework,
and finally moving back into their full work.
So for table -- sorry -- for Stage Zero,
we move to Stage One when the student can sustain concentration for 30 minutes
before symptoms worsen,
and when you give them a break, those symptoms start to reduce.
We move them then into that return to a partial day
where we --
again, build the one to three classes
and we move them to Stage Two as their symptom status improves
and they can tolerate now a greater number of hours
and where those breaks will be effective.
We move them to Stage Three -- from Two to Three --
when now again symptoms are continuing to improve and they can --
they can actually move it down,
and so forth and so on,
until they are back to their full program.
So again, this is just a more logical way
of thinking about increasing their activity.
What does it require?
It requires regular symptom monitoring,
the ACE Care Plan -- as part of our --
our CDC Toolkit.
We have a variety of things that we do with coaching kids,
getting around sleep and around using their symptoms as their guide.
Again, different accommodations that could be put in place over time.
Again, we begin to scale these back as the youngster is better.
But as you could see again,
we might shorten the day, shorten the classes,
particularly those high school classes that are 90 minutes.
Those can be a real challenge.
Building in rest breaks throughout the day,
allowing for extra time,
kind of trimming back the homework load to start with, teaching them to --
to do their homework in chunks with rest breaks in between,
either having no testing or modifying the testing,
and only as symptoms and their preparation allow.
they may need to chop it up into various pieces.
And again, thinking about for those kids where their work
has kind of backed up on them with the schedule for make-up work.
In a relatively small number of kids,
they may need a 504 Plan, or something
that now is more significantly structured to guide them in their recovery.
So let me talk about the --
This is a program
that we have been doing with kids that have more prolonged recoveries.
But I will tell you it may be a program
that we may want to think about doing for lots of kids.
and two groups did this program very independently,
but in many ways very similarly.
and within a few months,
John Leddy and Barry Willer at University of Buffalo
published a paper with a very similar program,
which is one of structured and monitored physical activity
that you engage the youngster in a progressive, controlled way.
And you do it to a level where they do not have a symptom worsening,
the two papers --
Here are
the John Leddy paper here where again,
the treatment with controlled exercise was found to be safe and appeared to improve
the post-concussion syndrome type symptoms, when compared
with a no treatment baseline.
trying to increase some chemicals that come to the brain.
This is the brain drive neurotropic factor,
which is used as a very important chemical that helps normal development,
let alone injury repair,
but we think of also is important for our cognitive abilities
as we age as well,
so I tell that to my adult audience here.
Also increasing cardiovascular activity is very important,
getting the blood moving,
which also helps with brain vascular function and perfusion.
We also increase endorphins --
This is a -- these are important,
important hormones that we know can help with mood, with alertness,
and these things have downstream effects on brain development,
helping again with brain repair,
with general physical conditioning,
helping the brain regulate itself, improving mood --
all critical things
that can have positive effects on post-concussion symptoms.
And there is some promising data right now on this that we think is useful.
that looks at the role of activity in normal individuals, again,
increasing that brain drive neurotropic factor,
and this is after 60 minutes of cycling at 55 percent of their maximum
and you can actually see increases in this very important chemical in the brain.
We do this with our kids where we teach them to kind of move
up the effort scale here.
We will teach them, you know,
to start at an easy or adjust the early strain level.
say an effort level of three here.
or on an elliptical or something,
you know, kind of non-jarring, where we just get them moving.
They rate their symptoms ahead of time with that rating scale
that we showed you before.
Maybe they start out with a headache of two, a fatigue of one,
a dizziness of zero, a noise and light sensitivity of zero,
a fogginess of one.
They do the activity here and they rate it at --
afterwards -- you know, a two,
maybe a two and so forth,
and they can -- we can say did it have a significant effect or not?
or sometimes we tell them just to repeat it over a couple of days
maybe up to an aerobic activity of --
of four to five to six,
we sort of increase them slowly over time,
putting all those good chemicals into the brain.
So again, here you have, as we have said,
a student who identified with a mild TBI -- what do you do?
All right?
One of the things we want to talk about is the team.
Now this is something that as Brenda mentioned before is very important
and the BrainSTEPS website, www.brainsteps.net,
will allow you to take advantage of the Concussion Management Team training,
Who can -- who can develop that team?
Who can be the ones that receive the youngster
that take on the role of being the liaison with the medical provider
and the community, with the family, with the teachers.
So we -- in
the management activities and responsibilities
before the school year, and developing
policies and procedure, developing your team, examining the various methods
that you need to put in place, educating people,
and then having a list of resources
in your community that you can access when you need to access them.
I like to think about how does this play out for any given youngster.
Well, so what we want to think about here is -- again, injury occurs,
you want to know that the medical team has evaluated the youngster,
and the symptom profile has been defined,
and the school person, whoever that point person is,
has been informed of the injury.
Then we want to think about a gradual return
So again, school makes or receives the initial plan
as they got it from the medical team,
maybe they used something like the ACE Care Plan,
or they used something it sounds like what the BrainSTEPS
has a combinations plan that they use,
which sounds like a good tool,
and we think about bringing the student back again,
when the symptoms become tolerable
and they can tolerate about 30 or so minutes of activity.
We then move on to what happens during the year itself and --
and then after,
the initial accommodations are defined,
team leader informs the teachers of the symptoms
and the likely accommodations, the student then comes back,
and we, based on the symptom status,
how many breaks do they need,
what other kinds accommodations,
like reduced amount of production, and --
and then we monitor that over time
where someone is defined as the periodic monitor.
Remember this is an important component that we cannot ignore.
It drains lots of energy,
it really colors the world of that youngster in their recovery.
as well as to the rest of the academic team,
and then as the youngster gets better, these adjustments are made
to the accommodations where they need less and less.
We might use something as a -- a symptom monitor list,
of the Concussion Management Team set of tools -- the toolkit.
The team again, liaisons with the medical providers regarding progress,
they may get some more input from the medical folks,
again, accommodations are --
are constantly being implemented and modified to the point of supervised --
and then potentially, depending on your school system,
you may require medical clearance, particularly as the youngster
goes back to P.E. or other kinds of risk activities,
certainly including sports.
An Eleventh Grade student slips and falls in a crowded hallway on the way to class.
They brace for the fall but hit the back of her head on an open locker,
cutting the skin and bleeding.
She is initially slow to get up, stumbles,
and walks toward the wrong bathroom, who wants to go in.
You observe this all happen.
The school nurse is not in that day.
What do you do as a school staff person?
Now I will tell you, in this scenario there are a couple
Somebody hits their head on a locker and cuts the skin and starts bleeding.
Oftentimes that becomes the focus of attention.
And now we think about that external wound and what needs to happen, all the while,
They may have lots of other symptoms.
We have to remember these injuries to the brain can be invisible
And we go through all of the symptoms with the youngster.
So this scenario is critically important.
What would we do, okay?
We showed you the kinds of ways that it can play out,
the kinds of functional effects,
the types of classes that can be affected,
the levels of concern that kids can have,
as well as parents,
how it seems that as you move from elementary to middle to high school,
those effects seem to become greater.
Those are likely because of the demands that are placed in those --
those, you know --
at the increasing grade levels.
Number Two, school learning
can potentially have a significant effect on recovery from the concussion.
by overworking the brain during that energy crisis.
In fact, kids will oftentimes get bored,
because they know they can do more,
and to find that sweet spot of activity as they are progressively recovering.
Understanding the unique symptom profile of that student is -- is critical.
It becomes the basis for which all programming occurs.
And then as the youngster is improving,
that active, ongoing communication between medical, school team,
and family occurs in a very, very regular way.
I should probably add this is --
this is important if the student is not improving,
if the student is not improving,
that we would expect.
with an active, regular symptom management program
where the student is playing an active role
where then applying and adjusting the types and intensity
of supports that that student needs.
If we can put all of these things together in place
for a student with a concussion,
so all really important things.
So what are the next steps we want to think about here?
which is that we need to be sure that we systematically train our school personnel,
but also our medical personnel about this whole return to school issue.
I could tell you that as a clinician in my clinic,
this is the source of the greatest stress that kids have.
Yes, they want to go back to a sport or yes,
they want to go back to doing things with their friends
or to driving or to doing whatever is important to them.
But they get very, very stressed and anxious
the greatest shout-out to Pennsylvania and the BrainSTEPS program
for now training over 700 schools --
that and it is a real model for -- for our country.
We need to obviously improve --
continue to improve our service delivery
and the coordination amongst the players, the medical, the school, and the families.
We are all busy and to be able to coordinate that can be a challenge.
But if you define the team members,
give them those roles, develop that expectation,
Finally, we know that we need to understand these injuries better
and that includes what kinds of treatments are most effective
for the different kinds of recovery outcomes
and symptom profiles that we have here,
so we have some work to be done,
but we can certainly do a lot of things
that ultimately are going to help kids return.
that she wants to --
to give us --
>> Thank you so much, Dr. Gioia.
Your information is always so pertinent
and so up-to-date with the current research,
that we thank you for sharing all of your up-to-date information with us,
so thank you, thank you. >> My pleasure.
>> And any of you --
if anyone does have any further questions,
feel free to send an email to me and I will get with Dr. Gioia
and he will answer our questions.
I know some of you had a couple little questions
and I did write those down.
to Learn Concussion Management Team in your school,
please go to our website, brainSTEPS.net,
and look at the reasons why you should have a brain --
a concussion management team --
and how to form one.
The training is free, the training is online, and --
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