Returning to Learn Following a Concussion
Written by Karen McAvoy, PsyD
The field of concussion is becoming aware that returning to learn (RTL) following a concussion is of parallel importance as returning to sport (RTS). In fact, a successful RTL is a necessary requirement BEFORE an athlete can start their gradual return to play steps. However, there remains much confusion about when to return to school, how to return to school and will using the brain for academics cause a delay in recovery of the concussion? This article will attempt to explain how RTL following a concussion is a process of active and progressive rehabilitation.
Before a student can return to learn, they must first return to school. It bears saying -- there is NO medical clearance for return to school. There is NO medical clearance for return to learn. There is only medical clearance for return to sport! (Return to Play (RTP) legislation - Senate Bill 11-040 in Colorado)
- Return to School refers to the actual return to the concussed student physically into the school building. Return to school is based upon the student’s symptoms, ability to manage those symptoms throughout the day and the school’s readiness to receive that student back. The decision to return a student to school falls primarily on the student and the parent, NOT the healthcare provider. The healthcare provider often does not see the concussed student soon enough, does not see the student frequently enough and certainly does not see the student daily, in the morning, to make the decision about going to school that day. A parent need not wait to see a healthcare professional to return their child to school. The American Academy of Pediatrics recommends that a concussed student return to school when symptoms are “tolerable, short-lived and amendable to rest” (Halstead et al. 2013, p. 952). Therefore, it is not necessary for a student be “symptom-free” to return to school. The newest research shows that 70% of students between the ages 5 to 18 will resolve from their concussion in 28 days (Zemek, 2016). That means that healthcare providers who are holding concussed students out of school until they are “symptom-free” are potentially holding them out of school for up to 1 month. This is contra-indicated for a concussion and leads to serious downstream consequences of social isolation, depression, anxiety and unsalvageable grades and credits
- Return to Learn refers to the teacher’s ability to adjust the academic demands up and down for the concussed student (hourly, daily, weekly) throughout the school day to maximize the student’s learning while minimizing symptoms. A low level of symptoms is to be expected at school depending upon the time of day, the student’s pre-concussion strength or weakness in a particular class and the teacher’s style of teaching. A teacher need not wait for medical input to increase or decrease classroom or homework expectations. The healthcare provider often does not see the student frequently enough to weigh in on classroom recommendations. Moreover, RTL recommendations from healthcare providers are often not relevant or realistic. For example, a healthcare provider might think that sunglasses are a helpful intervention for light sensitivity. However, sunglasses in class, for up to 4 weeks, is not helpful or realistic. A teacher may choose instead to provide a set of teacher notes, a seat closer to the board and an adjustment of the font on the computer as more effective interventions for light sensitivity.
In the early years of concussion research, there was a belief that a student with a concussion should be kept in a dark room with no stimulation for days or weeks. This was called “cocooning” (Lee, 2009). New research has debunked this practice. Current research now shows that more rest is not necessarily better for concussion recovery. An emergency room study assigned a control group to 1 to 2 days of rest followed by a gradual re-introduction of activity (home and school activity). The intervention group was assigned to 5 days of strict rest. The 5 days of rest group demonstrated higher reports of symptoms and slower recovery than the control group (Thomas et al., 2015). This study has led to the practice that the majority of students with a concussion return to school somewhere between the 1st and 2nd week of school. They are not expected to be symptom-free; they will need to learn to “pace their energy” to keep symptoms at a sub-symptom threshold, but they should be back to school within days, not weeks.
One of the most confusing RTL myths is that when a student returns to school, it is said, they should not look at a computer or book. This is not true nor is it realistic. Again, a student’s grades and learning will suffer if they never look at a book or computer for up to 1 month. A student may look at a book or computer, perhaps for a shorter period of time, followed by a small (5 to 10 minute) eye/brain breaks in the classroom. It has been helpful for a student, parent or teacher to think less of a concussion as a brain bruise, but instead as an “energy crisis”. Following a concussion, the cells that fuel the brain are temporarily inefficient. They are not broken; they are recovering daily and weekly. However, they are simply not consistently holding a charge. I like to help my students understand a concussion by telling them that with a concussion, they are like an iphone4, not an iphone7. They are not broken; they are just not holding a charge for long enough periods of time. When the brain begins to run on empty, symptoms act as an indicator light. The symptoms become a way for the student to take stock in how well they are “managing” their energy. Students need to “pace their energy” differently to stay charged all day and to keep symptoms at bay (McAvoy, 2016). Students need to “do, then fuel”. Fueling can be small 5 minute eye/brain breaks in the classroom, water breaks, bean bag breaks. It is helpful to remind students that all home and school activities require energy – so the student can help themself by cutting down texting, video games, computer screens for social media, socializing and extracurricular activities. Remember, home activities should be “limited” not restricted completely. It is not realistic to tell a teenager to never text or socialize. The home and the school plan need to be realistic in order for the student to be compliant. The student needs to be “taught” to be an active participant in their own concussion rehabilitation.
The greatest academic intervention a teacher can give a concussed student is a removal of non-essential work or a reduction of semi-essential work. Since learning is inefficient and compromised over 4 weeks, teachers need to consider what is most important to focus on during this 4 week period of slowed processing speed, limited memory/learning and flaring of symptoms due to variable levels of mental fatigue. It is helpful for a teacher to be cognizant of the student’s energy levels, how those manifest into symptoms and should assign a reasonable level of in-class work and homework. Teachers can also consider creative and alternative ways to assess demonstration of mastery during this compromised time – with oral presentations, group presentations, collages, open book, etc. instead of simply pushing through with testing as usual.
If class material is absolutely essential during the concussion, and if the demonstration of mastery cannot be altered in any fashion, holding back on testing or a deadline might be necessary. However, all too often, teachers rely solely on allowing concussed students to make-up work later instead of removing work. Postponing work is not helpful as it will be impossible for a concussed student to make-up all past work and jump right back in with current work at 4 weeks. As stated above, the greatest “gift” a teacher can give is a removal of non-essential work and a reduction of semi-essential work. This is the best way to keep learning going over 4 weeks, keep grades up, keep anxiety and frustration down and minimize long-term grade and credit problems. However, I always tell my students that a teacher cannot give you these “gifts” if you have not been present in class for instruction. This circles us back to the notion of concussion rehabilitation and the importance of the student learning to manage their symptoms well enough to be present at school every day, all day. There is no research that supports a partial return to school is better than a full day return to school. If students can learn to “pace their energy” well enough to keep their symptoms at bay, they need to be in every class, listening and learning, with “gifts” from their teachers.
The energy theory allows students, parents and teachers to understand that as each day and week progress, the student is expected to get better and better, can last longer throughout the day with less symptoms and can add in more home activities (more texting, more socializing) and more academics (more in-class/homework, quizzes/tests). Physical exertion is usually also slowly and simultaneously increased over this time. The international return to play guidelines require that there be no concussion symptoms in order to start the return to play steps. Therefore, a student must be 100% back to their pre-concussion learning level BEFORE they can be approved to start progression back to their sport. Everything a parent and teacher can do to help a concussed student get back to their pre-concussion level of learning is, in fact, an intervention to getting them back to the field as soon as possible. Not all athletes do return to their sport, but all students must return to their learning at school or work for decades to come. Facilitating a quick and flexible RTL plan makes a big difference in helping our students become the future teachers, doctors and entrepreneurs of our world.
Senate Bill 11-040, Jake Snakenberg Youth Concussion Act. www.leg.state.co.us/clics/clics2011a/csl.nsf/fsbillcont2/.../$FILE/040_01.pdf
Halstead, M., McAvoy, K., Devore, C., Carl, R., Lee, M., Logan, K., … Guinn-Jones, M.
(2013). Returning to Learning Following a Concussion. Pediatrics, 132(5), 948–957. doi:10.1542/peds.2013-2867
Zemek, R., Barrowman, N., Freedman, S. B., Gravel, J., Gagnon, I., McGahern, C., ... &
Craig, W. (2016). Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. Jama, 315(10), 1014-1025. doi:10.1001/jama.2016.1203
Lee, M. 2009. www.stamfordadvocate.com
Thomas, D., Apps, J., Hoffmann, R., McCrea, M., & Hammeke, T. (2015). Benefits of
strict rest after acute concussion: a randomized controlled trial. Pediatrics, 135(2). 213-223. https://doi.org/10.1542/peds.2014-0966
McAvoy, K. Rocky Mountain Hospital for Children, Center for Concussion.
REAP Guidelines. Available at: www.REAPconcussion.com. Accessed June 18, 2017
McAvoy & Eagan Brown (2017). Get Schooled on Concussions: Return to Learn (RTL)
http://www.getschooledonconcussions.com. Accessed April 3, 2016
Karen McAvoy, PsyD is dually credentialed as a clinical and school psychologist. She has spent 28 years as a brain injury specialist/educator through the Cherry Creek School District and the Colorado Department of Education. She is currently the Director of Psychology with the Center for Concussion at Rocky Mountain Hospital for Children. Dr McAvoy is the author of REAP and the co-founder/owner of www.GetSchooledOnConcussions.com.