Return to Learn

Concussions are a type of brain injury that are caused by a bump, blow or jolt to the head that causes the brain to move rapidly back and forth resulting in a chemical imbalance that effects the proper function of the brain. A concussion can result in the following:

• physical symptoms – headache and dizziness
• cognitive symptoms - difficulty concentrating, short -term memory problems or slowed mental processing 
• sleep symptoms - difficulty falling asleep or staying asleep, increased fatigue or altered sleep schedule
• emotional symptoms - irritability, sadness or anxiety.

Temporary cognitive struggles can create anxiety in student athletes and their families. Students need support from those in all areas of their lives such as coaches, teachers, school administrative staff, medical providers and family. It is very important that we can all be on the same page to make returning to school smooth and effective.

Points of emphasis

Return to learning should be initiated by a licensed healthcare provider and a written plan should be generated for school staff to be able to assist and set up a plan at school.

There should be a primary point of contact at each school. This can be the school nurse, athletic trainer or school guidance counselor; this may differ by school.

There is no “cookie cutter” approach or length of time to recovering from concussions. For return to learning to be effective, all involved need to understand this and be flexible. The process will likely involve some trial and error.

Focus on mastery learning- completing schoolwork that shows the student has mastered a subject, not more. This focus on essential academic assignments reduces anxiety about falling behind in school when it is difficult for students to keep up with a full workload. Anxiety can be a factor in slower recovery if assignments mount up.

Early intervention – Starting to develop a plan early in the injury course – is helpful in many ways:

1. It can alert teachers and school staff that help is needed.
2. It decreases anxiety about falling behind in school, which can complicate recovery for the student athlete
3. It leads to better communication and trust between medical providers, school staff and families

How concussion can affect school performance:

• Slower processing speeds
• Lapses in short term memory
• Reduced/impaired concentration
• Slower to learn new concepts
• Short attention span

Phased approach to return to learning:

Phase 1- No school/complete cognitive rest

• Rest at home, limited cognitive stress, focus on getting good sleep at night. Symptoms are most severe in this stage and tolerance of even basic tasks can be difficult
• Interventions-
  • No homework, tests or quizzes.
  • Avoid screens (television, cell phones, tablets, computers) or reading

This phase is typically short lived- potentially just a few days.

Phase 2- School work at home before return to classroom

• Trial of short assignments or reading with frequent breaks. Start with no more than 15-30 minutes of schoolwork in a stretch.
• Focus on staying below symptom threshold.
• Provide student with a complete set of notes for missed classes.

Phase 3- Partial school attendance with accommodations

• Recognize each student will be different in tolerance and may still have easily provoked symptoms.
• Focus on attending core classes that are tolerable. Initially, just being able to handle being in class without worsening symptoms is the goal.
• No make-up work or large assignments at this stage.
• No testing or quizzes

The goal of this phase is to initially see how the student tolerates the school environment (classroom noise, hallways, lights). The student will need breaks from class even if only attending a few classes. As the student’s symptoms improve more time in class and more assignments will be tolerable without significant worsening of symptoms.

• Breaks can be in the nurse’s office, library or other designated area
• Step up gradually, potentially not more than one new class per day
• Avoid band, choir, wood shop or PE

Students often struggle with classes with lots of new learning- math, foreign language and higher-level science. All parties must be patient with this process. The student may be equally as frustrated as the teachers by slow progress.

Phase 4- Full school attendance with accommodations

• Attending a full day of school, though student may still need intermittent breaks if symptoms recur. Typically, no or minimal symptoms at this phase.
• May start planning appropriate load of make up work. Consider eliminating some missed assignments. Mastery learning should be the focus. 
• Restarting testing is an option, but only one per day. 
• Restarting physical activity or PE per treating physician, considering light aerobic exercises such as walking or riding an exercise bike is often appropriate. Aerobic exercise can be therapeutic if it does not exacerbate symptoms. This also may begin at an earlier phase, particularly in prolonged recoveries.

Phase 5- Full school attendance without accommodations

• No or minimal symptoms at this stage. If a full day of school is tolerated without symptoms, consider advancing to phase 6.
• Hopefully, an appropriate plan for make up work has been established at this phase.
• Academic testing may take place as long as the student has had adequate time to learn material.
• Physical activities may be taking place per discretion of treating physician and athletic trainer.

Phase 6- Full school attendance and return to sports/extracurricular activities

• The student/athlete should be back to baseline (symptoms and function compared to before injury). 
• Return to play guidelines should be followed to get athlete back into sports.
• There may be continued make up work depending on the length of injury recovery.

**Every student athlete will not necessarily need to go through each phase in their return to learning program. There will be individual variability, so flexibility is important. In milder cases, some students will not even need a return to learning plan.

**Students with longer recoveries may require a specialized learning plan such as a 504 plan or IEP.

References

Return to Learn after a Concussion: A Guide for Teachers and School Professionals. luriechildrens.org/sports