jonathan french, psyd neuropsychology fellow frenchje@upmc
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Effects of Concussions on Academic Functioning and Case Presentation. Jonathan French, PsyD Neuropsychology Fellow [email protected] University of Pittsburgh Medical Center Department of Orthopaedic Surgery UPMC Sports Concussion Program. 15 year old, Sophomore - PowerPoint PPT PresentationTRANSCRIPT
Jonathan French, PsyDNeuropsychology [email protected] of Pittsburgh Medical CenterDepartment of Orthopaedic SurgeryUPMC Sports Concussion Program
Effects of Concussions on Academic Functioning and Case Presentation
15 year old, SophomoreHonors student, High Average standardized testing No other medical history-no prior concussion
Strong migraine history in maternal family
In retrospect, difficulties with concussion started on September 11, 2009
Case Example: High School Quarterback
Initial injury in video caused bilateral blurred vision, dizziness, photo/phonphobia, nausea, difficulty with play calls
No LOC, amnesia or mental status changeNever reported hit or symptoms to ATC, though told teammates Second event in video worsened symptoms
That evening, told parents of symptoms (minimized difficulties)No other medical intervention
Played remainder of seasonSymptoms ebbed/flowed depending upon exertion and contact to headGrades dropped during course of season (Straight A’s to C range)Symptoms persistent throughout entire seasonSustained “another” concussion 10/30/09 (2nd to last game)-posterior blow
• Reported to ATC week after game/Referred to UPMC
Case Example: High School Quarterback
Show Video
November 16, 2009 Evaluation (2 Months after initial event)Headaches daily in school (7/10-generalized pressure), moderate fatigue, “feeling slow”, fogginess, general dizziness, distractible, short term memory difficultyDiscussed inherent pressure of playing quarterback, team culture of playing through injury, pressure from coaches/family/friends
“Knew it was concussion, but nothing serious”“Would be fine in long run”“Good time to report injury given break from conditioning-no football responsibilities”
Father nonchalant, mother very concerned-discussed team/community culture of football
Physical evaluation indicated convergence insufficiency, provocative dizziness with horizontal/vertical saccades and gaze stability, balance WNLImPACT Testing
Case Example: High School Quarterback
Show ImPACT Data
Recommended formal Vestibular Evaluation (UPMC-Eye and Ear Institute/Center for Rehabilitation Services)Patient strongly desired to remain in school
Allowed ½ days for 2 weeksProvided full academic accommodations-including no tests for 3 weeks, ½ work assignments, books on tape if possible, extensions on all assignments, leaving class early, avoiding high stimulus areas, excused absences from school-recommended meeting with all teachers
Return evaluation in 2 weeks to monitor status
Case Example: High School Quarterback
Background of Academic Accommodations
• In the early 2000’s, due to the increase of concussion, schools approached UPMC to help develop a plan for students with concussion
• UPMC’s sports concussion program wanted to collaborate with local schools to create an educational plan for individuals who are have a head injury
• This lead to a creation of an Academic Accommodations form, which has been ever changing since it’s inception, and we continue to want to work with schools to improve it
Impact of School and Learning on mTBI
• Most educators, parents, and medical providers are aware of the deleterious impact of physical exertion on concussion symptoms and recovery, and are compliant with recommendations to reduce physical activity.
• Cognitive Exertion (Thinking) and the added stimulation of the school environment can significantly increase symptoms, even when the student has begun to recover
• Research has demonstrated generalized hyperactivation with concussion that is likely related to symptom increases when returning to school.
• Obvious Means: Testing, Group Work, Movies, Shop Class, Overhead lighting
• Subtle or Hidden Causes: Background noise (cafeteria, movement during and between classes), Taking notes (especially off of a projector), Sustained attention
Understanding the Symptoms Help to determine appropriate accommodations HUGE individual differences Can be Cognitive, Somatic, or Emotional Can wax and wane throughout the day
1st period “ok” by 8th they are struggling Student may not look or even act injured
Students are able to laugh when they are concussed
Some are able to continue to do well Don’t assume someone is “faking”; but we are
aware this occurs
Symptoms in the Classroom– Cognitive Difficulties
• Attention/Concentration Problems
• Difficulty with memory• Slowed processing• Difficulty with Multi-
tasking– Physical Symptoms
• Difficulty to do well, if in significant pain
• Convergence Insufficiency• Vestibular Dysfunction
– Sleep Disruptions• Not sleeping at night it is
difficult to perform well in school
• Fatigue throughout the day
– Emotional Instability• Anxiety about catching up
When Accommodations Fail…• Communication problems: Staff are not aware of the
injury or the severity of the problems (parents, guidance counselor, school nurse are key)
• Education problems: Staff shrug off injury because the student “looks fine,” “just had his/her bell rung,” or “this is only their first concussion, I had 10 when I played football and it didn’t bother me” (individual differences)
• Resistance: Because of the extra time and effort involved in accommodations, staff are resistant to providing notes, checking off assignments, etc.
Goals of Academic Accommodations
• Goals: A collaborative effort– Create a way for educators to know that the student is injured and based on the
evaluation, understand that certain tasks would provoke symptoms and prolong recovery
– To help students learn the core information needed to move on, without effecting their recovery
– Do not want students grades to suffer because of the injury– Balance between recovery, academics, and normal activities– Provide the right environment for recovery, as quick as possible
• It is NOT: – UPMC telling you how to educate these students
• You are the educational professionals• We want to collaborate with schools
– A “pass”– Dismiss them from work/learning
• The recommendations were made based on the assessment at the time of the visit
• Recommendations part of treatment for this medical condition
• Formalize a 504 plan if necassary
Attendance Recommendations
• No school• Initiate Homebound education• Half days
– Modified days – core classes, extra study periods• Full Days
Testing
• Students will not be as effective in testing situations, and they most likely will exacerbate symptoms
• Modifying test schedules, length, format, etc. is beneficial
Reducing and Modifying Workload
• Reduce the amount of total work• Modify the work by shortening assignments• Changing modalities• Auditory learning• Audit Classes
Notes, Breaks and Extra Time• Note taking can be extremely provocative of
symptoms• Have the student listening to lectures having pre-
printed notes, scribes, etc.
• Allow the students to take breaks throughout the day
• Allow students extra time to complete assignments
Other Accommodations
• Allow students the opportunity for food and water if needed to help with symptoms
• Due to light sensitivity, allow sunglasses• Modify computer screens• Modify busy/disturbing environments• No gym class
SUMMARY– Communication at all levels is key
• Both educators and treatment providers should work together
– Give the student the right environment to recover– Recovery is quicker and safer when students receive a
consistent message from all involved in their care– Discussing options with injured student can be
empowering– Ideally, injured students’ grades should not suffer due to
this temporary disability– “Healthy” appearance of student is usually a difficulty– Utilize available references, and encourage
students/parents/administration to do the same
November 30 Evaluation Vestibular evaluation indicated convergence insufficiency, difficulties with dynamic visual acuity, VOR exercises provocative for dizziness, posturography WNL
Home-Based PT outlined, Patient compliant
Symptoms not improved and persistentPatient vocalized concerns over injury, response from coaching staff, etc.
“Play through pain culture”Both parents understanding and concernedTeachers helpful at providing accommodationsFather trying to “educate” others regarding injury
Vestibular screening improved, but remained abnormalImPACT Testing
Case Example: High School Quarterback
Show ImPACT Data
Continued Vestibular Therapy-no exertion until WNLRecommended homebound instructionRecommended medication referral
Dr. Camiolo-Medical Advisor-UPMC Sports Concussion ProgramAmantadine 200mg
Follow up in 2-3 weeks
Case Example: High School Quarterback
NEUROPSYCHIATRIC • More emotional• Sadness• Nervousness• Irritability
COGNITIVE SYMPTOMS• Attention Problems• Memory dysfunction• “Fogginess”• Fatigue• Cognitive slowing
SLEEP DISTURBANCE • Difficulty falling asleep• Sleeping less than usual
MIGRAINE (PHYSICAL SX)• Headaches • Visual Problems• Dizziness• Noise/Light Sensitivity• Nausea
Factor Analysis, Post-Concussion Symptom Scale (Pardini, Lovell, Collins et al. 2004)
N=327, High School and University Athletes Within 7 Days of Concussion
NOTE:*Off-label use
Emotionality
SSRIsEscitalopram (Lexapro)
Sertraline (Zoloft)
Therapy
Sleep Disturbance
Melatonin
Trazodone
Cognitive Symptoms
NeurostimulantsAmantadine*
Methylphenidate*
Atomoxetine (Strattera)*
Somatic Symptoms
Headaches Prophylaxis Propranolol*
Verapamil*
Amitriptyline*
Escitalopram (Lexapro)
Sertraline (Zoloft)
Vestibular Therapy
UPMC Concussion ProgramTreatment/Rehabilitation Protocol
December 18, 2009 (3 months post-injury) Headaches 1/7 days (1/10, 20 minute duration), mild perceived difficulty with short-term memoryNo other symptoms reportedDischarged from Vestibular therapy-all WNLStarted Exertional Physical Therapy
Sean Learish,PT-Center for Rehab Services-Director of Exertional PT- UPMC Sports Concussion Program
ImPACT Testing
Case Example: High School Quarterback
Show ImPACT Data
December 18 recommendationsReturn to full school, minimal accommodations (breaks from class if needed, tutoring in difficult classes, extensions all assignments)Progress with exertional therapy to Stage 3-4No contact sportsContinue AmantadineFollow up 1 month
Case Example: High School Quarterback
January 11, 2010 (4 months post-injury) Off AmantadineReported circumscribed short term memory difficultiesDoing well in school-full curriculumNo other symptoms reportedStage 4 Physical Exertion-no difficultiesVestibular screening WNLImPACT Testing
Case Example: High School Quarterback
Show ImPACT Data
January 11, 2010 Recommendations Continue Exertion as toleratedFollow up in February for monitoring of status
Case Example: High School Quarterback
February 22, 2010 Evaluation100% asymptomatic-no difficulties reportedFull physical and cognitive exertionGrades returned completely to normal
Case Example: High School Quarterback
Show ImPACT Data
February 22, 2010 RecommendationsFull clearance back to all sports, including footballQuotes from Family:
Both “Felt educated about injury”Strong desire to “educate others”Reported misperceptions of others
Concussion is always repetitive and cumulativeSon has “permanent damage”Son would “never” return to footballSon would “never be the same cognitively or physically”Son should “never play football again” (from same people who questioned veracity of injury to begin with)“Poor education throughout community-from coaches to clinicians”
Without academic accommodations probably would have taken even longer to recover
Case Example: High School Quarterback