Mar 5, 2018Treating the Athlete: A Smarter Return
When it comes to treating an athlete with a concussion, most athletic trainers are focused on return-to-play protocols. Those ahead of the curve are implementing a return-to-learn process, too.
At Diamond Bar (Calif.) High School, Athletic Trainer Chase Paulson (far right) has spearheaded a system that gradually returns student-athletes with head injuries to their academic work. Here, he poses with (from left to right) Athletic Director Albert Lim, teacher Teresa Hebert, and student-athlete Matthew Emanuele, who went through the protocol.
When one of your athletes is diagnosed with a concussion, what crosses your mind as the athletic trainer overseeing their care? You likely take a moment to consider the appropriate steps to return them to physical activity. Perhaps you also think about how their day-to-day life will be affected. But how many times have you wondered whether the injury would impact your student-athlete in algebra, English, biology, or history?
Designing and implementing a return-to-learn protocol-a plan for supporting the concussed student-athlete in the classroom and gradually getting them back to full academic performance-is essential. However, this important step is often overlooked.
A return-to-learn protocol outlines how a head injury should be managed by school personnel. It can cover many areas of focus, such as student-athlete behavior and academic performance during recovery. Having one in place is necessary for three reasons:
- It mitigates risk in the event of litigation by forming a paper trail of a student-athlete’s post-injury care.
- It makes certain that proper state concussion laws are upheld.
- It ensures that best practices are followed for the sake of the patient.
Despite its significance, enacting a return-to-learn plan definitely has its challenges. It takes collaboration, cooperation, and communication among all parties involved.
You might think that someone on the academic side of things should handle these tasks. But in reality, athletic trainers are the perfect people for this job. We can ensure that all groups are free from bias when making decisions about student-athlete health care, and we can document daily progression or regression of symptoms to guarantee athletes resume activity with their cognitive health intact.
When I set out to design our return-to-learn protocol at Diamond Bar (Calif.) High School, I first worked to get the necessary parties on board. But my job didn’t stop there. Keeping everything operating smoothly is a process that requires continuous monitoring to ensure the best outcome for the athlete and the school.
The first-and probably most challenging-step in building a return-to-learn plan is getting support from administrators, teachers, coaches, and parents. They often have misconceptions about what the return-to-learn process entails, but effectively communicating the benefits with them can establish a solid foundation to build on.
At Diamond Bar, our administrators, academic counselors, and coaches initially thought that having an official procedure for getting concussed athletes back in the classroom would involve tons of additional paperwork. With our administrators, we explained the process and provided them with a portion of a developed protocol to analyze and comment on. This gave them a better understanding of what the approach should be. Our principal jumped on board when he heard the phrase “reduce our risk for potential litigation,” and the rest of the support staff soon followed.
Our teachers’ union was pretty quick to accept the protocol because they knew it would support cognitive ability and decrease the likelihood that concussed student-athletes would suffer setbacks in learning. They valued the effort put into the plan’s creation and realized that it would not increase their own workload. Rather, it would decrease the likelihood that they would be called into question for mishandling a case.
Diamond Bar’s coaches already knew I take concussions very seriously, but the possibility of having to wait for an injured athlete’s academics to catch up with athletics brought pushback. They immediately viewed a return-to-learn period as extra time missed from participation. I held meetings and had conversations to help them understand that ensuring cognitive healing first would ultimately increase athletic performance upon return.
The coaches’ attitudes ultimately shifted when one of our student-athletes suffered a concussion that caused a decrease in grades and academic performance. This once-4.0-GPA student was barely pulling a 3.0 just months after sustaining a head injury. While the coaching staff focused more on how the concussion affected the individual’s ability in their sport, they eventually saw the cognitive impact of the injury when the player couldn’t remember their correct position for plays at practice. This led the coaches to support the return-to-learn protocol moving forward.
Parents were the easiest group to get on board with the plan. Since Diamond Bar is an academic-driven institution, classroom performance, GPA, and test scores mean more to parents than on-field success. Knowing that their child’s brain function was being cared for after an injury gave them peace of mind.
Yet, some questioned the length of time required before a child could be cleared to resume activity and a full load of coursework-usually at least seven days. I held numerous conversations with these individuals and explained how the protocol would preserve their students’ academic success. Data from previous injuries, such as test scores, modifications used during the school day, and a symptom checklist, made them realize that students often struggled in class after a concussion, even when they didn’t report issues to parents at home. With the new protocol, there would be no hiding these symptoms anymore.
Once we got everyone on board, the next step in our process was to create a Concussion Management Team with members representing the various areas of return to learn. This group includes me, our school nurse, our health clerk, each student’s counselor as the case arises, our athletic director, our school psychologists, and our student affairs administrators.
Determining which components each person is responsible for gives them ownership of their role and guarantees buy-in. For example, our athletic director facilitates communication with off-campus coaches, while our school psychologists provide social-emotional support and help with any necessary 504s or Individualized Education Plans (IEP).
PLAN IN ACTION
With a team assembled, we put our return-to-learn protocol into effect. When a Diamond Bar athlete is suspected of having a concussion, they are evaluated by either the health office staff or me, depending on whom the student-athlete initially reports to. If I care for the injury first, I e-mail the Concussion Management Team to initiate the protocol. If the student-athlete is seen in the health office first, that staff follows a similar process.
Then, the injured student-athlete and their parents are directed to see a physician trained in treating concussions. We provide a copy of the athlete’s symptoms and any concussion testing we have administered so the doctor can make an informed decision about the next steps. The physician also fills out our school’s Concussion Management Form, which includes three sections:
• An official diagnosis of concussion or head injury as defined by California state law.
• Academic Activity Status (return to learn), where the physician can indicate if the student may benefit from supports in the classroom.
• Physical Activity Status (return to play), again as defined by California state law.
In the second section, the physician can suggest any academic modifications for us to make. This is important because concussion symptoms may be triggered by the learning environment, the volume of mental activity required to complete coursework, or the pressure to return to normal academic levels placed on student-athletes by parents or teachers. These accommodations can include:
• Decreasing or limiting class time.
• Taking rest breaks during classes.
• Decreasing screen time or electronic device use.
• Leaving lights on during class if a projector is in use.
• Increasing print size on handouts or other materials.
• Placing the student-athlete at the front of the class to limit eye strain.
• Limiting noise levels and busy areas of the classroom to ensure a calmer learning environment for the student-athlete.
• Allowing extra time to complete coursework/assignments and tests.
• Lessening homework load by a certain percent.
• Postponing significant testing.
• Allowing rest breaks during the day as needed.
When physicians request these supports, we also ask that they provide a suggested end date for them. This allows teachers to observe how the return-to-learn protocol can help during the acute care of injury and decreases the chances that a student-athlete will abuse the system. Once we receive the completed Concussion Management Form, the school nurse sends a letter to the student-athlete’s teachers explaining the individual supports needed.
Occasionally, implementing these academic accommodations may be challenging. For example, you might face a teacher who does not want to help monitor symptoms. By law, our teachers must comply with medical supports prescribed by the physician. But they do not have to take part in the collaborative process of gauging the student’s progress, and we did once have a teacher who declined participation.
Another roadblock can be individual biases to student-athlete supports. We have had instances where teachers felt that athletes-namely football players-abused their academic accommodations when recovering from concussion. Typically, a phone call with the teacher, followed by a conversation with the student-athlete and their parents, resolves the issue. (See “Case Study” below.)
Any additional formal academic modifications, including 504 plans and IEPs, should involve the school psychologist, school nurse, counselor, and administration. For further guidelines on these documents, refer to your district protocols and/or state education code.
We have used 504 plans two or three times since our return-to-learn protocol was first created. They are most commonly implemented when an athlete’s concussion symptoms linger for more than three weeks or when they are put on home-hospital (our district’s term for when a student is visited by teachers instead of going to school due to health reasons). If an athlete shows any decline in their academic achievements post-injury, an IEP may be put into place for further support.
Once necessary academic accommodations are in place, the next step in the return-to-learn protocol is ensuring the athlete is progressing smoothly. As part of this, they come to the athletic training room daily to meet with me.
Then, I record the symptoms they experienced that day by using a concussion symptom inventory from the SCAT-5 (Sport Concussion Assessment Tool-Fifth Edition). The SCAT-5 tracks 22 symptoms in three categories: physical, emotional, and psychological. It also asks if the symptoms get worse with physical or mental activity, which often leads to a conversation about how the student-athlete progressed through that day’s classes. The last question prompts the athlete to rate their current functioning as an overall percentage of their normal functioning. We developed a sheet that compares each day’s scores to the previous day’s so we can advance or stabilize recovery as needed.
However, because I don’t see athletes all day, every day, I need additional symptom monitoring help from teachers and counselors, especially given the time-sensitive nature of concussion care. What may seem like a minor issue to one teacher could expand into a larger problem at the end of the day or during the later stages of recovery.
A tool that can help with this is a daily concussion symptom tracker. For instance, we hope to start using a shared online document stored on a cloud-based server through Google Forms or SurveyMonkey. Then, teachers or academic counselors can quickly (in five minutes or less) use it to comment on a student-athlete’s daily appearance or behavior and alert other team members of any complications that arise. Example questions in the document may include:
• How did the student-athlete appear today-normal or abnormal? If abnormal, what was different about their appearance?
• How did the student behave during class-normally or abnormally? If abnormally, what was different about their behavior?
• Did the student-athlete complain of any concussion symptoms during the class period? If so, what were they?
Once our teachers or counselors start recording an athlete’s symptoms throughout the day, it will give me a better overall understanding of the concussion symptom timeline. This will enable me to determine the best ways to support the athlete and assist teachers and other staff.
BACK TO NORMAL
When student-athletes are able to get through a regular school day symptom-free, they are instructed to schedule a follow-up appointment with their physician to get clearance to start the return-to-play process. We still keep the academic supports in place just in case any symptoms reemerge during return to play. The determination of normal function is self-reported by the student-athlete and clarified by teacher feedback.
In total, it typically takes our student-athletes seven to 14 days to resume full academic and athletic participation following a concussion, which includes the time they spend in our return-to-learn and return-to-play protocols. California state law dictates that there must be a minimum of seven days after a head injury before a player gets back to their sport. Yet, student-athletes often take longer than seven days to become asymptomatic, go through a full day of school, and complete the return-to-play process.
Once an athlete is cleared to resume full activities, this is communicated to our Concussion Management Team and the necessary teachers so they know that academic supports are no longer needed. From this point on, the Concussion Management Team is no longer notified about the athlete unless a setback occurs.
Return-to-play criteria have gotten much of the attention thus far when it comes to managing concussions, but return-to-learn protocols are just as important. When a collaborative plan is designed, implemented, and modified as needed, it minimizes setbacks and allows for maximal functioning and learning.
Last fall, a j.v. football player at Diamond Bar (Calif.) High School sustained a head injury at an away contest. When he returned to campus later that evening, our athletic training staff performed a full concussion evaluation, our concussion management protocol was activated, and our Concussion Management Team was notified via e-mail. The athlete was then sent home to rest, with instructions to see a physician as soon as possible.
The player’s mother took him to the doctor, who completed our Concussion Management Form. The student-athlete was officially diagnosed with a concussion and was told to return to school with the following academic supports:
• Allow extra time to complete coursework/assignments and tests.
• Lessen homework load by 50 percent.
• No significant classroom or standardized testing.
Two days following the injury, the student-athlete visited the athletic training room for his daily symptom assessment and said, “My teacher wouldn’t allow me to skip my English test today, and I totally failed. I had a headache all period, and she just didn’t believe me.”
In compliance with our return-to-learn protocol, I e-mailed his English teacher to discuss the situation. As it turned out, the teacher thought the student was simply acting out based on his previous behavior in class. I explained that concussed students can often mask their symptoms with behavioral changes or deny their symptoms because they just want to be back to normal. The teacher understood that we were collecting data on the player’s daily symptoms and that his headache always appeared while reading during English class-so he wasn’t faking it.
The teacher then complied with our supports, removed the athlete’s bad test grade, and allowed him to make up the test when he was released for full academic participation. He scored an 83 percent on the re-test, which was average for his academic performance.
Over the next few days, we continued to monitor the athlete’s symptoms daily, and his headaches eventually diminished. After a week, he was reviewed again by his physician, and his academic supports were lifted. The English teacher and I had a follow-up conversation once this happened to make sure she stayed in the loop.
One week after the athlete’s full academic release, the English teacher called me to discuss his behavior in class. She reported that he was acting out, being defiant, and generally making the class period a negative experience for the other students. She thought he was trying to abuse his injury and supports by blaming her for putting too much pressure on him when he was hurt.
This phone call initiated a meeting between the student-athlete, his parents, the English teacher, the student-athlete’s academic counselor, the school nurse, and me to ensure that something was not missed during recovery. The meeting unveiled no significant or lingering issues stemming from the original concussion.
Rather, the athlete admitted he had been trying to get an extension or excuse for a missed assignment. Because the teacher knew his academic supports were no longer necessary, she denied him, and he acted out in defiance. The athlete’s parents agreed that he was no longer suffering any concussion symptoms and should not have been given any more supports. Thus, all parties were on the same page once the appropriate information was communicated.
The student-athlete was reprimanded for his poor behavior in class, and the situation was resolved peacefully. Since then, he has successfully returned to play with no reoccurring issues from his original injury.
This example highlights how a return-to-learn protocol can work. Effective communication between members of the Concussion Management Team and a thorough process documenting daily symptoms kept the student-athlete’s academic performance from suffering. It also shows how teamwork among members of a concussion task force can prevent athletes from taking advantage of the system.
This article appeared in the March 2018 issue of Training & Conditioning.