September 21, 2017

Studies inconsistent on when concussed students should return to learn, policies and protocols may be needed

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Reintegration into school has been a noticeably neglected area of focus in concussion research, particularly in comparison to research on return-to-play. When and how a student should be fully integrated into the classroom are just two questions UAB and Children’s of Alabama researchers are looking to answer.

Youth who have sustained one or more concussions may experience challenges when they return to the classroom and integrate back into active learning. Investigators at the University of Alabama at Birmingham and Children’s of Alabama have reviewed literature and studies focused on returning to academics postconcussion to identify a full range of themes and gaps in research that need to be addressed.

According to Dreer, research on factors associated with the reintegration of concussed students is limited and focuses on getting them back into the classroom, but lacks the precision of how much cognitive rest is needed to maximize brain recovery and when to begin to participate in school-related activities and fully integrate back into school.

“Research surrounding concussed students’ returning to learn is noticeably lacking compared to that focused on return-to-play issues,” said Laura Dreer, Ph.D., director of the UAB Psychological and Neuropsychological Clinical Research Services. “Parents, educators and pediatricians often struggle with how much cognitive rest is needed to let the brain heal, and how and when to safely integrate students back into the classroom without exacerbating symptoms, like headaches.”

Other questions physicians and educators are often asked are related to what types of accommodations are needed for concussed students, who should be coordinating concussion management in the school setting and/or between systems of care, and what to do if the student’s symptoms do not resolve within a few days or weeks. Just like pressure some athletes feel in terms of returning to play, similar pressures can occur to get students back into learning.

“Doing so prematurely or unsafely may cause more harm than good,” Dreer said. “The problem is that there is other evidence suggesting that keeping students out of school can also contribute to negative consequences. Unfortunately, the current research is just too limited in this area to draw hard conclusions, causing confusion for clinicians, educators, parents, coaches/athletic trainers, and students when trying to manage concussions.”

Concussion management has become an important area of research on which Dreer and colleagues at UAB and Children’s of Alabama are focused. The multidisciplinary team of investigators and stakeholders are studying traumatic brain injury effects from a physical and mental perspective as part of several ongoing projects and efforts to inform the public of evidence-based practices that should be in place, particularly with return-to-learn policies.

concussions classroom graphic“The attention to concussions on a national level has further compounded the problem, which can lead to misinterpretation of information and cause unnecessary alarm,” Dreer said. “The fact of the matter is there are a lot of unknowns at this point in time. On the positive side, this has led to greater attention to concussion awareness, training and research. We want to help provide informed answers to these types of questions.”

Research results are fairly inconsistent in providing clear conclusions for concussion protocols to safely return students to learning. The literature review takes a deeper dive into the science surrounding concussion management within academics in order to develop rigorous concussion policies, practice guidelines, and dissemination and training efforts.

Dreer and her team are working with a variety of important stakeholders, including the Alabama Department of Education, Children’s of Alabama, schools, organized sports and recreation teams, parents, and students, as well as others at the state and national levels, as part of this important effort and concussion initiatives at UAB and Children’s of Alabama.

The literature review Dreer and her colleagues conducted found five key themes within current research, including academic outcomes, physician recommendations, length of time to complete return-to-learn, concussion-related symptom difficulties, and academic accommodations or guidelines.     

According to Dreer, research on factors associated with the reintegration of concussed students is limited and focuses on getting them back into the classroom, but lacks the precision of how much cognitive rest is needed to maximize brain recovery and when to begin to participate in school-related activities and fully integrate back into school.

Academic tasks such as learning, reading, writing/typing, studying, completing homework assignments, and test taking rely on a variety of different aspects of brain functioning, such as attention, speed of processing, working memory, short- and long-term memory, visual and auditory processing, consolidation of new information, planning and organization, flexibility in thinking, initiation, comprehension, and fine motor functioning. A concussion, depending on the severity and other factors, can interfere with these important functions of the brain temporarily for hours, days or several weeks or in some cases permanently.

“Our ultimate goal is to influence return-to-learn policies and consensus guidelines for concussed students’ returning to learn. These policies should have agreed-upon protocols to help guide systems of care in the amount of cognitive rest a student should have after a concussion, as well as specific recommendations of frequent communication between care providers and required education and training programs for stakeholders.”

This can impact a student’s ability to fully engage in and keep up with academic demands. That is why it is so important to monitor concussion symptoms in light of rest and tolerance of symptoms when gradually returning to learn. While the majority of concussion symptoms typically subside in most individuals within a few days to weeks, a subset of individuals may be at risk for more prolonged recovery and challenges with returning to learn or other activities in daily living, as well as their emotional well-being.

“Another important aspect to consider is a history of a learning disorder, behavioral or mental health problems, or previous concussions that should also be considered in return-to-learn decisions,” Dreer said. “Making sure students receive the appropriate accommodations is important for ultimate success in school.”

Published in a special issue on pediatrics in the American Psychological Association’s journal, Rehabilitation Psychology, the review confirms that the return-to-learn process among children can be challenging and protocols are needed to foster transition into full participation in academic tasks. Concussed children should be integrated into learning with a multidisciplinary system of care, which includes physicians, parents, educators and the student, to fully transition the brain into learning successfully.

Gaps in current research include a lack of consensus on return-to-learn protocols, agreement on prescription of cognitive rest, guidance for return-to-learn protocols, understanding of communication between systems of care, concussion-related education for systems of care, evidence-based programs or interventions for return-to-learn, and the impact on return-to-learn outcomes.

“Our ultimate goal is to influence return-to-learn policies and consensus guidelines for concussed students’ returning to learn,” Dreer said. “These policies should have agreed-upon protocols to help guide systems of care in the amount of cognitive rest a student should have after a concussion, as well as specific recommendations of frequent communication between care providers and required education and training programs for stakeholders.”

Several concussion research, dissemination and training efforts between UAB and Children’s of Alabama are ongoing. As the director of Concussion Research Initiatives, Dreer and her concussion investigators and community stakeholders are at the forefront of studying this important public health issue. Ongoing studies from these initiatives are designed to better identify: how much cognitive rest is needed for whom, the impact of active versus passive learning on recovery, neuropsychological predictors related to return-to-learn, factors related to prolonged recovery, concussion management training for educators and families, and development of novel strategies to improve communication patterns between systems of care postconcussion, among many other topics.

Dreer also emphasized there are other important populations impacted by concussions and traumatic brain injuries that her team is studying and in need of evidence-based guidance on prevention, education, detection and treatments, such as the military and older adults who are at risk for falls, as well as family members who serve as caregivers.

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