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APRIL 2015 :: 76(2)
Traumatic Brain Injury in North Carolina

Traumatic brain injury (TBI) can range from mild concussions to life-threatening trauma. This issue of the NCMJ discusses various issues related to TBI, including the impact of North Carolina’s motorcycle helmet law, prevention and management of sports-related concussions, the need for behavioral health care for TBI survivors, the effect of TBI among North Carolina’s veterans, management of TBI among older adults, and advances in prehospital care for TBI.

INVITED SIDEBAR

Return-to-School Protocols Following a Concussion

Elizabeth Newlin, Stephen R. Hooper

N C Med J. 2015;76(2):107-108.PDF | TABLE OF CONTENTS



Concussion is emerging as a major public health concern, with incidence rates on the rise due to advances in recognition and general public awareness [1]. Despite this concern, we lack clear evidence as to how a concussion affects school functioning or how students should be managed in the school setting following a concussion. In this regard, return-to-school protocols generally remain nonexistent or, at best, their delivery and execution are inconsistent [2, 3].

The problems typically seen following a concussion (eg, headache, physical and cognitive fatigue, double vision, light sensitivity, loss of attention, slower processing speed) can all negatively impact a student’s functioning in school. To facilitate full reintegration into the social and academic aspects of the school setting, proactive management of the student’s symptoms should be considered on an individual basis [4-6]. While concussion management guidelines have been offered in the sports arena via professional organizations (eg, the American Medical Society for Sports Medicine) and legislative actions (eg, the Gfeller-Waller Concussion Awareness Act), similar guidelines and policies are only beginning to emerge for the return-to-school component of concussion management [7, 8].

Policies and Procedures
Gioia and colleagues have proposed 5 key components of a return-to-school policy: the formation of an interdisciplinary team with documented expertise in brain injuries, including concussion; professional development of all school-based personnel; screening/identification, assessment, and developmental surveillance; accommodations and interventions; and medical-school communication (unpublished data, 2015). While no state has addressed all of these proposed components in a comprehensive policy, several states have begun to advance strategies, policies, and procedures to address the needs of students who have sustained a concussion. For example, the BrainSTEPS Program in Pennsylvania has trained a large number of interdisciplinary teams to address the return-to-learn aspects of concussion [9]; in Oregon, a comprehensive training program is available for all school personnel [10]; and in North Carolina, an online curriculum is available for school personnel, with a particular focus on school psychologists [11].

In North Carolina, the Wake County Public School System has begun developing and implementing policies and procedures to facilitate the return-to-learn needs of students with concussions. These procedures protect the student during their recovery phase, are generally not costly or time consuming, and span the core policy requirements proposed by Gioia and colleagues. Examples of these procedures include the following:

For athletic injuries that fall under the scope of the Gfeller-Waller Concussion Awareness Act, there is a mandatory e-mail alert to a designated school professional from the coach or athletic trainer of the student who was pulled from play for a suspected head injury. For other students, any first responder health care provider can provide this alert. This alert allows the designated school professional to be in communication with parents regarding potential educational accommodations related to a concussion diagnosis, and it alerts teachers to observe the student for educational issues associated with a concussion. Teacher education is also an important aspect of the return-to-school process so that all school-based professionals are knowledgeable about concussions.

An interdisciplinary team then collaborates with the parents, school staff, health care professionals, and the student in providing accommodations as the student transitions back to school. A collaborative team approach with all stakeholders provides for the best management of the student’s post-concussion education [12].

The education plan may indicate the need for accommodations like a partial-day schedule, postponing testing until the student is symptom-free, pacing homework or assignments to allow for cognitive rest, rest during the school day, providing pain medication for headaches, and/or limiting noise or light distractions [1]. The education plan is developed with the counselor, educator, parent, and student in collaboration with written recommendations from the physician and the interdisciplinary team. For students who have persistent symptoms, a referral for special education evaluation can be discussed with the family, the medical provider, and the interdisciplinary team. Similarly, the student’s medical plan is developed in collaboration with the parent, student, physician, and school nurse. This plan provides support for physical complaints such as headaches, light sensitivity, and/or noise sensitivity.

The student’s educational and medical plans are evaluated at least every 2 weeks, or whenever a doctor’s note is presented. In most cases, symptoms resolve in 1–3 weeks. In cases where symptoms or problems persist past 6 months, or in cases where the extent of the injury warrants further evaluation, the student may be referred for additional assessment.

Conclusion
In North Carolina, there has been some movement by individual school systems toward developing policies and procedures to address the return-to-school needs of students who have sustained a concussion. Actively linking these policies and procedures to ongoing state initiatives—such as the mandated training for school psychologists working with students following a brain injury, diabetes and asthma management in the school setting, and the Gfeller-Waller Concussion Awareness Act—should facilitate more coordinated management and, hopefully, better outcomes for all students following a concussion.

Acknowledgments
Potential conflicts of interest. E.N. and S.R.H. have no relevant conflicts of interest.

References
1. Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K; Council on Sports Medicine and Fitness; Council on School Health. Returning to learning following a concussion. Pediatrics. 2013;132(5):948-957.

2. Master CL, Gioia GA, Leddy JJ, Grady MF. Importance of ‘return-to-learn’ in pediatric and adolescent concussion. Pediatr Ann. 2012;41(9):1-6.

3. McAvoy K. Return to learning: going back to school following a concussion. NASP Communiqué. 2012;40(6):23-25.

4. Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collins MW, Meehan WP III. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014;133(2):e299-e304.

5. Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24):2250-2257.

6. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008;43(3):265-274.

7. DeMatteo C, Stazyk K, Singh SK, et al. Development of a conservative protocol to return children and youth to activity following concussive injury. Clin Pediatr (Phila). 2015;54(2):152-163.

8. McAvoy K. Providing a continuum of care for concussion using existing educational frameworks. Brain Inj Prof. 2012;9(1):26-27.

9. Pennsylvania Department of Education, Brain Injury Associatioin of Pennsylvania, Pennsylvania Department of Health. BrainSTEPS website. https://www.brainsteps.net/. Accessed January 16, 2014.

10. University of Oregon, Center on Brain Injury Research and Training (CBIRT). Resources. CBIRT website. http://cbirt.org/ocamp/resources/. Accessed January 16, 2014.

11. UNC Carolina Institute for Developmental Disabilities. Traumatic brain injury. Carolina Institute for Developmental Disabilities website. http://cidd.unc.edu/SchoolPsychology/TBI/. Accessed January 16, 2014.

12. Halstead ME, Walter KD; Council on Sports Medicine and Fitness. Clinical report—sport-related concussion in children and adolescents. Pediatrics. 2010;126(3):597-615.


Elizabeth Newlin, RN, BSN, NCSN Wake County Public Health school nurse; co-chair of the Children and Youth Committee, North Carolina Brain Injury Advisory Council, Raleigh, North Carolina.
Stephen R. Hooper, PhD professor, associate dean, and chair, Department of Allied Health Sciences, University of North Carolina School of Medicine, Chapel Hill, North Carolina.

Address correspondence to Dr. Stephen R. Hooper, University of North Carolina School of Medicine, 1028 Bondurant Hall, CB #4120, Chapel Hill, NC 27599 (Stephen_hooper@med.unc.edu).