592879
research-article2015
CPJXXX10.1177/0009922815592879Clinical PediatricsWing et al
Original Article
Heads Up: Communication Is Key in School Nurses’ Preparedness for Facilitating “Return to Learn” Following Concussion
Clinical Pediatrics 1–8 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815592879 cpj.sagepub.com
Robyn Wing, MD1,2, Siraj Amanullah, MD, MPH1,2, Elizabeth Jacobs, MD1,2, Melissa A. Clark, PhD1, and Chris Merritt, MD, MPH1,2
Abstract Background. Recent literature advocates for a school academic team, including school nurses, to support concussed students’ return to the classroom. This study aimed to assess the current understanding and practices of a sample of school nurses regarding the concept of “return to learn” in concussed students. Methods. Cross-sectional survey of New England school nurses. Results. The greatest barrier to the school nurses’ functioning within the academic rehabilitation team for students with concussion was “inadequate communication with the provider that diagnosed the concussion” (73%). Of the 151 school nurses surveyed, 19% felt that they did not have the training necessary for this role. Other barriers included “inadequate concussion training” (38%) and “inadequate time necessary to care for a student with concussion” (30%). Conclusions. By identifying specific gaps in knowledge and challenges at the school level, these results inform interdisciplinary medical teams about the importance of educating and facilitating effective “return to learn” academic plans. Keywords concussion, head injury, mild traumatic brain injury, school nurses, return to learn, return to school, pediatrics
Introduction Each year in the United States, an estimated 100 000 to 140 000 children and adolescents are diagnosed with concussion.1-3 The pathophysiology of concussion involves a neurometabolic cascade resulting in altered cerebral blood flow and glucose metabolism.4,5 These changes in brain physiology result in myriad physical symptoms including headache, nausea, vomiting, balance problems, and visual problems. In addition, concussion causes many cognitive and emotional symptoms, including difficulties with concentration or memory, neuroagitation, and impulsivity, which pose particular challenges when concussed students return to the academic setting.6,7 Both physical and cognitive activity after a concussion place additional metabolic demands on the brain during recovery. Therefore, concussion treatment has focused on mitigating postconcussive symptoms through a planned, graduated return to the child’s activities. While there are well-documented “return-to-play” guidelines for directing a student’s return to physical activities and athletics,3 historically there has been less
guidance to direct and assist with returning students to the classroom, which should be viewed as being the primary “work” of the school-aged child. Recommendations for “cognitive rest” following concussion, including limiting schoolwork, reading, and visually stimulating activities, are primarily driven by consensus reports and expert opinion with limited supporting evidence.6,8,9 Increased cognitive activity following concussion has been associated with longer recovery time and 1 week of cognitive rest during the acute or subacute healing phases has shown benefits in decreasing postconcussive symptoms and improved cognitive performance in some studies.10,11 Other studies have cautioned against periods of prolonged cognitive rest due to lack of evidence of efficacy and potential consequences of prolonged 1
Brown University, Providence, RI, USA Rhode Island Hospital/Hasbro Children’s Hospital, Providence, RI, USA 2
Corresponding Author: Robyn Wing, Hasbro Children’s Hospital, 593 Eddy St, Claverick 2, Providence, RI 02903, USA. Email: [email protected]
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absenteeism.12,13 A recent randomized trial showed that participants prescribed 5 days of strict bed rest had a slower resolution of concussive symptoms and a higher symptom burden 10 days after their injury than those participants prescribed usual care (1-2 days of rest, followed by a stepwise increase in activity).14 This delicate balance between rest and returning to cognitive exertion requires a careful, multidisciplinary, individualized approach to “return to learn” following concussion.15-18 Members of the family home, medical home, and educational home—each of whom have a unique perspective on the student’s rehabilitation—would ideally be involved in this process. In order to better direct the return-to-learn process, a recent clinical report from the American Academy of Pediatrics (AAP) serves as a framework to guide the concussed student to a successful and safe return to the classroom.15 This and other reports highlight the importance of a school academic team, which includes a school nurse, to aid in facilitating “return to learning.”15,16 School nurses may be called on to assist in identifying a concussed student, as well as to manage symptoms when students return to school.19,20 They have the unique and challenging perspective of observing students in their learning environment, are an important liaison between the medical and educational homes, and can aid in assessing students’ readiness for return to learning. The purpose of this study was to assess school nurse readiness to participate in concussion rehabilitation, the presence and nature of concussion rehabilitation policies at schools, and barriers to “return-to-learn” plans. We targeted school nurses because they are often the only health care provider in the “school academic team,” monitoring a concussed student’s return to the classroom. Little is known about the current concussion rehabilitation practices of these crucial health care providers on the “front lines” of care in schools. We investigated the presence of formal concussion education, strategies for helping concussed students in the school setting, and nurses’ comfort with being a part of an academic return-to-learn team. In addition, we assessed school nurse awareness of current AAP recommendations. We hypothesized that school nurses, who are being called on at a national level to be leaders of the academic rehabilitation team for concussed students, are not uniformly prepared for this role. As we develop our understanding of methods and mechanisms by which to reintroduce concussed students to the classroom, studies such as this will provide the basis for developing more effective “return-to-learn” teams and plans.
Methods This exploratory study utilized a confidential survey (see Supplementary materials, available online at http:// clp.sagepub.com/supplemental) distributed to school nurses at the annual New England School Nurse Association conference in May 2014 in Newport, RI. The target population was school nurses practicing in New England elementary, middle, and high schools in both the public and private sectors. All individuals who attended the conference (n = 183) were eligible for the survey, with no exclusions. The 2014 conference attendees were typical in number and characteristics relative to prior years’ conference attendees.
Questionnaire Design The questionnaire was designed after review of the pediatric concussion literature and of prior school nurse surveys.21,22 It was reviewed for content validity by a panel of 10 physicians and nurses with expertise in injury prevention and survey research. It was then piloted with a panel of 5 current and former school nurses who would not be in attendance at the conference. Feedback from this 2-step development phase was incorporated into the final survey instrument. The survey questionnaire solicited information about the school in which the nurse currently practiced, including the state, grade level and size of the school, and availability of health care providers at the school. The state of practice was of particular interest because each state in the region has different laws regarding student concussion management. A second section asked a series of questions about participant knowledge, understanding and experiences with pediatric concussion, and the frequency of school nurse visits for concussions. The final section collected personal demographic information and ended with a text box for commentary.
Data Collection Questionnaires were included in the registration packet for conference attendees along with a $5 certificate incentive. The first author was present at registration to answer questions and to facilitate survey collection. Questionnaires were deposited anonymously once completed. Completion of the survey was voluntary.
Data Preparation and Analysis Data from the paper-and-pen questionnaire was entered and analyzed electronically. Analyses included descriptive
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Wing et al statistics and correlations. Chi-square analyses were used to detect differences in response to concussion education and knowledge (including knowledge of AAP recommendations) by respondent characteristics, including state of practice and level of prior concussion education. Free text comments were coded by 2 researchers (RW and CM) for themes and reviewed for consistency. Representative quotations are presented to characterize the most prevalent themes in the respondents’ own words. This study was reviewed and exempted by the institutional review board at Rhode Island Hospital/Lifespan Corporation.
Results Of the 183 school nurses in attendance at the 2014 New England School Nurse Association conference, 151 completed the survey, for a response rate of 83%. Because all conference participants received a questionnaire, the cooperation rate was also 83%. The majority of school nurses who participated were full-time, female, with a bachelor’s degree or higher (Table 1). School nurses from all 6 New England states took part in the survey, with a higher proportion from Rhode Island, where the conference took place (Table 2).
Concussion Knowledge and Experience Over half (58%) of nurses reported specific education about pediatric concussion diagnosis and management. School nurses from Massachusetts and Maine were most likely to have had formal concussion management education, with 85% and 90% of nurses, respectively, compared to 42% to 58% in the other New England States (P = .005). From a list of potential symptoms, all (100%) participants identified headache as a symptom of concussion, with emotional changes being the least recognized concussive symptom (94%). Almost all participants (92%) were also able to recognize all symptoms of concussion asked in the survey (Table 3). This did not vary by level of education or state of practice. When queried about AAP-recommended strategies for helping concussed students in the school setting, the most commonly endorsed were “taking a break from class” (97%), “shortened class times/school days” (93%), and “facilitating longer time to take tests” (86%). Less commonly recognized strategies were “wearing a hat or sunglasses in school” (70%) and “using earplugs” (52%). When asked to estimate the proportion of concussed students requiring planned rest breaks during the school day, nurses’ responses varied broadly from less than 5% to greater than 50% (see Figure 1). Only 13% of school nurses were able to correctly identify 30 to 45 minutes as the amount of time that
Table 1. Personal Demographic Information. Variable Gender Male Female Provider type Full-time nurse Part time nurse Other Highest education level Diploma in nursing (RN) Associate degree Bachelor’s degree (BSN) Master’s degree Other Additional certifications Teaching certificate National school nurse certification CPR instructor certification No additional certifications Other Years ago completed formal training 0 to less than 5 years 5 to less than 10 years 10 to less than 20 years 20 years or more Years working as school nurse 0 to less than 5 years 5 to less than 10 years 10 to less than 20 years 20 years or more
% (n) 1% (1) 99% (149) 87% (128) 12% (17) 2% (3) 6% (9) 5% (7) 44% (66) 43% (65) 2% (3) 41% (62) 16% (24) 35% (53) 26% (39) 9% (14) 19% (28) 18% (26) 24% (35) 40% (60) 14% (21) 17% (25) 41% (62) 28% (42)
students should be able to tolerate learning prior to returning to academic activities following a concussion according to AAP guidelines.15 Even among those with formal concussion training, only 15% answered this question correctly, while 37% felt that there was no specified time published for how long students should be able to tolerate learning before returning to academic activities following concussion. Respondents expressed a need for education of parents, teachers, and administrators surrounding pediatric concussion management, as illustrated by the following comments: Parents do not really understand about concussions and push kids back too soon. (Respondent 18) You must teach the teachers about concussion. The issue of standardized testing drives their practice and they don’t understand what (concussion rehabilitation) limits mean. (Respondent 168)
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Barriers
Table 2. School Demographic Information. Variable
% (n)
State Rhode Island Massachusetts Connecticut Vermont New Hampshire Maine Number of students in school Fewer than 300 300 to fewer than 500 500 to fewer than 1000 1000 or more I do not know School type Public Private Other School level Elementary Middle High Other Percentage of students at or below FPL 75% to 100% 50% to less than 75% 25% to less than 50% Less than 25% I do not know Available health care resources at school Full-time school nurse Part-time school nurse Nurse’s aid Medical assistant School physician/LIP On-call school physician/LIP Health care center Other
41% (62) 17% (26) 17% (26) 9% (14) 8% (12) 6% (10) 21% (32) 36% (55) 30% (46) 9% (14) 3% (4) 89% (135) 7% (10) 5% (8) 64% (97) 36% (54) 33% (50) 3% (4) 9% (13) 23% (34) 21% (32) 40% (60) 8% (12) 93% (140) 15% (23) 1% (2) 2% (3) 11% (16) 12% (18) 7% (10) 8% (12)
Abbreviations: FPL, federal poverty level; LIP, licensed independent practitioner.
Table 3. School Nurse Knowledge of Concussive Symptoms. Variable Concussive symptoms Headache Difficulty concentrating Sensitivity to light or noise Balance problems Decline in school performance Emotional changes
% (n) 100% (151) 99% (150) 99% (149) 97% (147) 97% (146) 94% (142)
Nearly 1 in 5 (19%) participants felt that they did not have the training necessary to be a part of an academic rehabilitation team for a student with a concussion (strongly disagreed or disagreed with the statement “I have the training necessary to be a part of an academic rehabilitation team for a student with concussion”), while 75% felt adequately trained for this role. The most commonly endorsed barrier to the school nurse’s role as a member of the school academic team was “inadequate communication with the provider that diagnosed the concussion” (73%), followed by “inadequate concussion training” (38%) and “inadequate time necessary to care for a student with concussion” (30%) (Figure 2). Respondents reported more commonly being contacted by parents about a concussed student’s return to the classroom than by coaches, physicians, or teachers; 67% of nurses reported having been contacted by parents in the past 12 months. Fewer (42%) nurses reported having been contacted by a physician in the past 12 months to coordinate academic rehabilitation for students. One respondent commented: Often I do not receive any documentation from a physician. I may be notified by a teacher when they have a concern and I am not even aware of the diagnosis. (Respondent 24)
Respondents commented that they would appreciate receiving specific return-to-learn recommendations or forms from diagnosing health care providers. They noted that a lack of consistency of recommendations among physicians makes it difficult to implement academic accommodations and to communicate them clearly to the rest of the school community: Many physicians provide physical limitations when returning a student to school but eliminate any academic modifications needed in the classroom. (Respondent 45) I would appreciate communication from the health care provider delineating exactly how they want the child cared for in school. This I feel would give me direction and freedom to explain adequately to the school community. (Respondent 129)
While 40% of school nurses reported that their school had a policy in place to return students to athletics, only 30% reported a school policy for returning students to academics. At the state level, all New England states have enacted laws regarding return to play following a concussion, while none have policies for returning students to academics. School nurses were not generally aware of the lack of return-to-learn policies in their state legislatures:
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% Respondents
50
40
30
20
10
0 < 5%
5 to 10% 10 to 30% 30 to 50% % Concussed Students Requiring Rest Breaks in School
> 50%
Figure 1. School nurse estimation of proportion of concussed students requiring planned rest breaks.
Inadequate communication with provider that diagnosed concussion
Inadequate concussion training
Inadequate time necessary to care for student with concussion
Perception that being a member of the school academic team for students with concussion is not a school nurse's role
There are no barriers.
0%
10% 20% 30% 40% 50% 60% 70% 80%
Figure 2. Barriers to school nurse role as a member of the school academic team for students with concussion.
27% of school nurses surveyed erroneously thought there was a state policy for return to learn following concussion, while 45% were unsure of their state policy.
Discussion To our knowledge, this study is the first to attempt to quantify school nurse knowledge of pediatric concussion
and preparedness to act as members or leaders of the academic concussion rehabilitation team. While the majority of participants were able to recognize signs and symptoms of concussion, nearly 20% felt that they lacked the training necessary to be a part of an academic rehabilitation team for a concussed student. This finding supports the need for specific education of school nurses regarding concussion management in the academic setting.
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Concussive symptoms, both physical and cognitive, have direct and indirect effects on learning in school.15-17,23 Strategies to address graded return to academics include pain control, reduced exposure to light and sound, early dismissal from class to avoid crowded hallways, and reduced exposure to computers and videos. In addition, allowing for extra time for assignments and testing, postponing standardized testing, and having a note taker or scribe for the student may also be helpful for academic rehabilitation.15 Only 48% of school nurses in our survey correctly recognized all possible listed strategies to help a concussed student in the school setting. This emphasizes need for school nurse education about these strategies in order to advocate for their concussed students and the need for reassessment of students’ progress regularly. The single largest barrier identified to facilitation of school nurses’ leadership in academic rehabilitation is inadequate communication with the students’ other medical providers. While the diagnosis of concussion may occur at many points in a student’s care—from the sideline athletic trainer to the emergency department to the primary care physician’s office—the respondents to this survey clearly felt that this information was not being adequately relayed to the school academic team in a useful or timely manner. They commented that the lack of formalized guidelines for academic rehabilitation in the absence of specific instructions from the treating physician is detrimental to providing a unified approach for successfully returning students to the classroom. Indeed, one prior study found that only 11% of pediatric primary care providers provided written cognitive rest recommendations to patients following a diagnosis of concussion.24 Further complicating the management plan, there remains a lack of uniformity regarding how specifically to prescribe cognitive rest, and little scientific evidence for when and how much rest is necessary, which translates into little to no guidance for parents and nurses in the school setting. The general recommendation for “cognitive rest” may be difficult to implement practically. Compared to other clinical entities—in which recovery may be more accurately and objectively measured—it is often a challenge to provide an individualized concussion management plan needed for each patient. Furthermore, concussion does not have reliable prognostic indicators, making it difficult to estimate an individual’s recovery time or trajectory. While no formal policy for “return to learn” exists, the individualized approach to each patient can be guided by protocols that direct all members of the care team during a student’s recovery. There is increasing evidence that students benefit from a stepwise return-to-learn approach that mirrors return-to-play protocols.25-27 Using standardized
symptom monitoring tools, the goal is to find an appropriate level of cognitive exertion that does not exacerbate symptoms or cause reemergence of resolved symptoms. The plan, directed from the medical home and communicated to and enacted by the academic rehabilitation team, should start with cognitive rest and slowly advance to a full return-to-school activities. The AAP recommends that students should be able to tolerate 30 to 45 minutes of cognitive activity without emergence of concussive symptoms prior to returning students to the classroom.15 Only 13% of school nurses in our study were able to correctly identify this recommendation, which is an important first step in successful return to learning for concussed students. Finally, our study highlights one area for potential quality improvement at a legislative or policy level. Though all 50 states and the District of Columbia have enacted laws regarding returning concussed students to athletics, at the time of this study, no state in New England had a policy in place for returning students to academics, a fact of which most school nurses surveyed were unaware. Respondents commented on the need for a uniform policy and modes of communication between medical providers and school teams to replace the varied and often confusing health forms and discharge instructions currently in place. Local or regional concussion experts may be of invaluable assistance in directing or consulting on development of these policies, partnering with primary care physicians, emergency providers, school medical and academic teams, as well as local and state policymakers to provide up-to-date and uniform recommendations.
Limitations Our study did have limitations that must be considered. The chosen sampling frame, attendees of the annual New England School Nurses conference, is a regional sample and may not be representative of all school nurses in the United States. However, we do not anticipate any differences in concussion knowledge in New England compared to the nation due to relatively equivalent dissemination of concussion education and legislation. Additionally, the sample may be biased by including only those nurses motivated and able to receive continuing education in a conference setting. Therefore, assuming that our sample of school nurses may have more education than those not surveyed, our results may overestimate general school nurse knowledge of concussion. Finally, although the questionnaire was reviewed by expert panels and piloted prior to distribution, language about attitudes and comfort level may have been subject to varied interpretation.
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Conclusion
References
School nurses play a dynamic role in the care of concussed students. They are called on to be leaders or members of the school academic team for concussion rehabilitation, acting as both educators to school administration and faculty, as well as advocates for students. There has been limited focus on preparing school nurses for this responsibility, and 1 in 5 school nurses in our survey did not feel comfortable with this role. In order to empower those closest to students, future educational and legislative efforts should focus on school nurses. At the local level, concussion experts and programs should partner with primary care physicians and school physicians to develop uniform recommendations and forms to aid school nurses directing students’ return to the classroom. Physicians should provide every child diagnosed with concussion with written return-to-learn and return-to-play protocols to be discussed with the school academic team. On a larger scale, this study and others focusing on academic rehabilitation of concussed students are starting points for developing more effective “return-to-learn” plans. By identifying specific gaps in knowledge and challenges at the school level, these results can inform policymakers about the importance of including school nurses in legislation and mandated training. A comprehensive team approach to concussion management should facilitate better outcomes for students with concussion, including a quicker and more successful return to academics.
1. Bakhos LL, Lockhart GR, Myers R, Linakis JG. Emergency department visits for concussion in young child athletes. Pediatrics. 2010;126:e550-e556. 2. Meehan WP 3rd, Mannix R. Pediatric concussions in United States emergency departments in the years 2002 to 2006. J Pediatr. 2010;157:889-893. 3. McCrory P, Meeuwisse WH, Aubry M, et al Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;47:250-258. 4. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train. 2001;36:228-235. 5. Grady MF, Master CL, Gioia GA. Concussion pathophysiology: rationale for physical and cognitive rest. Pediatr Ann. 2012;41:377-382. 6. Halstead ME, Walter KD. American Academy of Pediatrics. Clinical report—sport-related concussion in children and adolescents. Pediatrics. 2010;126:597-615. 7. Howell D, Osternig L, Van Donkelaar P, Mayr U, Chou LS. Effects of concussion on attention and executive function in adolescents. Med Sci Sports Exerc. 2013;45: 1030-1037. 8. Harmon KG, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Clin J Sport Med. 2013;23:1-18. 9. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Athl Train. 2009;47:434-448. 10. Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collins MW, Meehan WP 3rd. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014;133:e299-e304. 11. Moser RS, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. J Pediatr. 2012;161:922-926. 12. de Kruijk JR, Leffers P, Meerhoff S, Rutten J, Twijnstra A. Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg Psychiatry. 2002;73:167-172. 13. Gibson S, Nigrovic LE, O’Brien M, Meehan WP 3rd. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj. 2013;27:839-842. 14. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135: 213-223. 15. Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K. Returning to learning following a concussion. Pediatrics. 2013;132:948-957. 16. Sady MD, Vaughan CG, Gioia GA. School and the concussed youth: recommendations for concussion education and management. Phys Med Rehabil Clin N Am. 2011;22:701-719. 17. McGrath N. Supporting the student-athlete’s return to the classroom after a sport-related concussion. J Athl Train. 2010;45:492-498.
Acknowledgments We thank the school nurses from the New England School Nurse Association who participated in this study.
Author Contributions RW and CM conceptualized and designed the study, designed the data collection instrument, coordinated and supervised data collection, carried out initial analyses and interpretation, and drafted the original manuscript. MC, SA and EJ assisted with study design, reviewed and revised the data collection instrument and reviewed the manuscript. All authors approved the final manuscript as submitted
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding was provided through a seed grant from the University Emergency Medicine Foundation of Providence, RI.
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18. 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. 19. Piebes SK, Gourley M, Valovich McLeod TC. Caring for student-athletes following a concussion. J Sch Nurs. 2009;25:270-281. 20. Wang LY, Vernon-Smiley M, Gapinski MA, Desisto M, Maughan E, Sheetz A. Cost-benefit study of school nursing services. JAMA Pediatr. 2014;168:642-648. 21. Ohio Department of Health. 2008 School Nurse Survey fact sheet. http://www.odh.ohio.gov/~/media/ODH/ ASSETS/Files/chss/school%20nursing/2008snsurvey. ashx. Accessed June 12, 2015. 22. Bergren MD, Monsalve L. The 2011 NASN Membership Survey: developing and providing leadership to advance school nursing practice. NASN Sch Nurse. 2012;27(1): 36-41.
23. McAvoy K. REAP the benefits of good concussion management. http://files.leagueathletics.com/Text/Documents/ 3365/28606.pdf. Accessed June 12, 2015. 24. Arbogast KB, McGinley AD, Master CL, Grady MF, Robinson RL, Zonfrillo MR. Cognitive rest and schoolbased recommendations following pediatric concussion: the need for primary care support tools. Clin Pediatr. 2013;52:397-402. 25. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008;43:265-274. 26. Gioia GA, Vaughan C, Reesman J, et al. Characterizing post-concussive exertional effects in the child and adolescent. J Int Neuropsychol Soc. 2010;16(suppl 1):178. 27. Lovell MR, Pardini JE, Welling J, et al. Functional brain abnormalities are related to clinical recovery and time to return-to-play in athletes. Neurosurgery. 2007;61:352-359.
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research-article2015
CPJXXX10.1177/0009922815592879Clinical PediatricsWing et al
Original Article
Heads Up: Communication Is Key in School Nurses’ Preparedness for Facilitating “Return to Learn” Following Concussion
Clinical Pediatrics 1–8 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815592879 cpj.sagepub.com
Robyn Wing, MD1,2, Siraj Amanullah, MD, MPH1,2, Elizabeth Jacobs, MD1,2, Melissa A. Clark, PhD1, and Chris Merritt, MD, MPH1,2
Abstract Background. Recent literature advocates for a school academic team, including school nurses, to support concussed students’ return to the classroom. This study aimed to assess the current understanding and practices of a sample of school nurses regarding the concept of “return to learn” in concussed students. Methods. Cross-sectional survey of New England school nurses. Results. The greatest barrier to the school nurses’ functioning within the academic rehabilitation team for students with concussion was “inadequate communication with the provider that diagnosed the concussion” (73%). Of the 151 school nurses surveyed, 19% felt that they did not have the training necessary for this role. Other barriers included “inadequate concussion training” (38%) and “inadequate time necessary to care for a student with concussion” (30%). Conclusions. By identifying specific gaps in knowledge and challenges at the school level, these results inform interdisciplinary medical teams about the importance of educating and facilitating effective “return to learn” academic plans. Keywords concussion, head injury, mild traumatic brain injury, school nurses, return to learn, return to school, pediatrics
Introduction Each year in the United States, an estimated 100 000 to 140 000 children and adolescents are diagnosed with concussion.1-3 The pathophysiology of concussion involves a neurometabolic cascade resulting in altered cerebral blood flow and glucose metabolism.4,5 These changes in brain physiology result in myriad physical symptoms including headache, nausea, vomiting, balance problems, and visual problems. In addition, concussion causes many cognitive and emotional symptoms, including difficulties with concentration or memory, neuroagitation, and impulsivity, which pose particular challenges when concussed students return to the academic setting.6,7 Both physical and cognitive activity after a concussion place additional metabolic demands on the brain during recovery. Therefore, concussion treatment has focused on mitigating postconcussive symptoms through a planned, graduated return to the child’s activities. While there are well-documented “return-to-play” guidelines for directing a student’s return to physical activities and athletics,3 historically there has been less
guidance to direct and assist with returning students to the classroom, which should be viewed as being the primary “work” of the school-aged child. Recommendations for “cognitive rest” following concussion, including limiting schoolwork, reading, and visually stimulating activities, are primarily driven by consensus reports and expert opinion with limited supporting evidence.6,8,9 Increased cognitive activity following concussion has been associated with longer recovery time and 1 week of cognitive rest during the acute or subacute healing phases has shown benefits in decreasing postconcussive symptoms and improved cognitive performance in some studies.10,11 Other studies have cautioned against periods of prolonged cognitive rest due to lack of evidence of efficacy and potential consequences of prolonged 1
Brown University, Providence, RI, USA Rhode Island Hospital/Hasbro Children’s Hospital, Providence, RI, USA 2
Corresponding Author: Robyn Wing, Hasbro Children’s Hospital, 593 Eddy St, Claverick 2, Providence, RI 02903, USA. Email: [email protected]
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absenteeism.12,13 A recent randomized trial showed that participants prescribed 5 days of strict bed rest had a slower resolution of concussive symptoms and a higher symptom burden 10 days after their injury than those participants prescribed usual care (1-2 days of rest, followed by a stepwise increase in activity).14 This delicate balance between rest and returning to cognitive exertion requires a careful, multidisciplinary, individualized approach to “return to learn” following concussion.15-18 Members of the family home, medical home, and educational home—each of whom have a unique perspective on the student’s rehabilitation—would ideally be involved in this process. In order to better direct the return-to-learn process, a recent clinical report from the American Academy of Pediatrics (AAP) serves as a framework to guide the concussed student to a successful and safe return to the classroom.15 This and other reports highlight the importance of a school academic team, which includes a school nurse, to aid in facilitating “return to learning.”15,16 School nurses may be called on to assist in identifying a concussed student, as well as to manage symptoms when students return to school.19,20 They have the unique and challenging perspective of observing students in their learning environment, are an important liaison between the medical and educational homes, and can aid in assessing students’ readiness for return to learning. The purpose of this study was to assess school nurse readiness to participate in concussion rehabilitation, the presence and nature of concussion rehabilitation policies at schools, and barriers to “return-to-learn” plans. We targeted school nurses because they are often the only health care provider in the “school academic team,” monitoring a concussed student’s return to the classroom. Little is known about the current concussion rehabilitation practices of these crucial health care providers on the “front lines” of care in schools. We investigated the presence of formal concussion education, strategies for helping concussed students in the school setting, and nurses’ comfort with being a part of an academic return-to-learn team. In addition, we assessed school nurse awareness of current AAP recommendations. We hypothesized that school nurses, who are being called on at a national level to be leaders of the academic rehabilitation team for concussed students, are not uniformly prepared for this role. As we develop our understanding of methods and mechanisms by which to reintroduce concussed students to the classroom, studies such as this will provide the basis for developing more effective “return-to-learn” teams and plans.
Methods This exploratory study utilized a confidential survey (see Supplementary materials, available online at http:// clp.sagepub.com/supplemental) distributed to school nurses at the annual New England School Nurse Association conference in May 2014 in Newport, RI. The target population was school nurses practicing in New England elementary, middle, and high schools in both the public and private sectors. All individuals who attended the conference (n = 183) were eligible for the survey, with no exclusions. The 2014 conference attendees were typical in number and characteristics relative to prior years’ conference attendees.
Questionnaire Design The questionnaire was designed after review of the pediatric concussion literature and of prior school nurse surveys.21,22 It was reviewed for content validity by a panel of 10 physicians and nurses with expertise in injury prevention and survey research. It was then piloted with a panel of 5 current and former school nurses who would not be in attendance at the conference. Feedback from this 2-step development phase was incorporated into the final survey instrument. The survey questionnaire solicited information about the school in which the nurse currently practiced, including the state, grade level and size of the school, and availability of health care providers at the school. The state of practice was of particular interest because each state in the region has different laws regarding student concussion management. A second section asked a series of questions about participant knowledge, understanding and experiences with pediatric concussion, and the frequency of school nurse visits for concussions. The final section collected personal demographic information and ended with a text box for commentary.
Data Collection Questionnaires were included in the registration packet for conference attendees along with a $5 certificate incentive. The first author was present at registration to answer questions and to facilitate survey collection. Questionnaires were deposited anonymously once completed. Completion of the survey was voluntary.
Data Preparation and Analysis Data from the paper-and-pen questionnaire was entered and analyzed electronically. Analyses included descriptive
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Results Of the 183 school nurses in attendance at the 2014 New England School Nurse Association conference, 151 completed the survey, for a response rate of 83%. Because all conference participants received a questionnaire, the cooperation rate was also 83%. The majority of school nurses who participated were full-time, female, with a bachelor’s degree or higher (Table 1). School nurses from all 6 New England states took part in the survey, with a higher proportion from Rhode Island, where the conference took place (Table 2).
Concussion Knowledge and Experience Over half (58%) of nurses reported specific education about pediatric concussion diagnosis and management. School nurses from Massachusetts and Maine were most likely to have had formal concussion management education, with 85% and 90% of nurses, respectively, compared to 42% to 58% in the other New England States (P = .005). From a list of potential symptoms, all (100%) participants identified headache as a symptom of concussion, with emotional changes being the least recognized concussive symptom (94%). Almost all participants (92%) were also able to recognize all symptoms of concussion asked in the survey (Table 3). This did not vary by level of education or state of practice. When queried about AAP-recommended strategies for helping concussed students in the school setting, the most commonly endorsed were “taking a break from class” (97%), “shortened class times/school days” (93%), and “facilitating longer time to take tests” (86%). Less commonly recognized strategies were “wearing a hat or sunglasses in school” (70%) and “using earplugs” (52%). When asked to estimate the proportion of concussed students requiring planned rest breaks during the school day, nurses’ responses varied broadly from less than 5% to greater than 50% (see Figure 1). Only 13% of school nurses were able to correctly identify 30 to 45 minutes as the amount of time that
Table 1. Personal Demographic Information. Variable Gender Male Female Provider type Full-time nurse Part time nurse Other Highest education level Diploma in nursing (RN) Associate degree Bachelor’s degree (BSN) Master’s degree Other Additional certifications Teaching certificate National school nurse certification CPR instructor certification No additional certifications Other Years ago completed formal training 0 to less than 5 years 5 to less than 10 years 10 to less than 20 years 20 years or more Years working as school nurse 0 to less than 5 years 5 to less than 10 years 10 to less than 20 years 20 years or more
% (n) 1% (1) 99% (149) 87% (128) 12% (17) 2% (3) 6% (9) 5% (7) 44% (66) 43% (65) 2% (3) 41% (62) 16% (24) 35% (53) 26% (39) 9% (14) 19% (28) 18% (26) 24% (35) 40% (60) 14% (21) 17% (25) 41% (62) 28% (42)
students should be able to tolerate learning prior to returning to academic activities following a concussion according to AAP guidelines.15 Even among those with formal concussion training, only 15% answered this question correctly, while 37% felt that there was no specified time published for how long students should be able to tolerate learning before returning to academic activities following concussion. Respondents expressed a need for education of parents, teachers, and administrators surrounding pediatric concussion management, as illustrated by the following comments: Parents do not really understand about concussions and push kids back too soon. (Respondent 18) You must teach the teachers about concussion. The issue of standardized testing drives their practice and they don’t understand what (concussion rehabilitation) limits mean. (Respondent 168)
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Barriers
Table 2. School Demographic Information. Variable
% (n)
State Rhode Island Massachusetts Connecticut Vermont New Hampshire Maine Number of students in school Fewer than 300 300 to fewer than 500 500 to fewer than 1000 1000 or more I do not know School type Public Private Other School level Elementary Middle High Other Percentage of students at or below FPL 75% to 100% 50% to less than 75% 25% to less than 50% Less than 25% I do not know Available health care resources at school Full-time school nurse Part-time school nurse Nurse’s aid Medical assistant School physician/LIP On-call school physician/LIP Health care center Other
41% (62) 17% (26) 17% (26) 9% (14) 8% (12) 6% (10) 21% (32) 36% (55) 30% (46) 9% (14) 3% (4) 89% (135) 7% (10) 5% (8) 64% (97) 36% (54) 33% (50) 3% (4) 9% (13) 23% (34) 21% (32) 40% (60) 8% (12) 93% (140) 15% (23) 1% (2) 2% (3) 11% (16) 12% (18) 7% (10) 8% (12)
Abbreviations: FPL, federal poverty level; LIP, licensed independent practitioner.
Table 3. School Nurse Knowledge of Concussive Symptoms. Variable Concussive symptoms Headache Difficulty concentrating Sensitivity to light or noise Balance problems Decline in school performance Emotional changes
% (n) 100% (151) 99% (150) 99% (149) 97% (147) 97% (146) 94% (142)
Nearly 1 in 5 (19%) participants felt that they did not have the training necessary to be a part of an academic rehabilitation team for a student with a concussion (strongly disagreed or disagreed with the statement “I have the training necessary to be a part of an academic rehabilitation team for a student with concussion”), while 75% felt adequately trained for this role. The most commonly endorsed barrier to the school nurse’s role as a member of the school academic team was “inadequate communication with the provider that diagnosed the concussion” (73%), followed by “inadequate concussion training” (38%) and “inadequate time necessary to care for a student with concussion” (30%) (Figure 2). Respondents reported more commonly being contacted by parents about a concussed student’s return to the classroom than by coaches, physicians, or teachers; 67% of nurses reported having been contacted by parents in the past 12 months. Fewer (42%) nurses reported having been contacted by a physician in the past 12 months to coordinate academic rehabilitation for students. One respondent commented: Often I do not receive any documentation from a physician. I may be notified by a teacher when they have a concern and I am not even aware of the diagnosis. (Respondent 24)
Respondents commented that they would appreciate receiving specific return-to-learn recommendations or forms from diagnosing health care providers. They noted that a lack of consistency of recommendations among physicians makes it difficult to implement academic accommodations and to communicate them clearly to the rest of the school community: Many physicians provide physical limitations when returning a student to school but eliminate any academic modifications needed in the classroom. (Respondent 45) I would appreciate communication from the health care provider delineating exactly how they want the child cared for in school. This I feel would give me direction and freedom to explain adequately to the school community. (Respondent 129)
While 40% of school nurses reported that their school had a policy in place to return students to athletics, only 30% reported a school policy for returning students to academics. At the state level, all New England states have enacted laws regarding return to play following a concussion, while none have policies for returning students to academics. School nurses were not generally aware of the lack of return-to-learn policies in their state legislatures:
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60
% Respondents
50
40
30
20
10
0 < 5%
5 to 10% 10 to 30% 30 to 50% % Concussed Students Requiring Rest Breaks in School
> 50%
Figure 1. School nurse estimation of proportion of concussed students requiring planned rest breaks.
Inadequate communication with provider that diagnosed concussion
Inadequate concussion training
Inadequate time necessary to care for student with concussion
Perception that being a member of the school academic team for students with concussion is not a school nurse's role
There are no barriers.
0%
10% 20% 30% 40% 50% 60% 70% 80%
Figure 2. Barriers to school nurse role as a member of the school academic team for students with concussion.
27% of school nurses surveyed erroneously thought there was a state policy for return to learn following concussion, while 45% were unsure of their state policy.
Discussion To our knowledge, this study is the first to attempt to quantify school nurse knowledge of pediatric concussion
and preparedness to act as members or leaders of the academic concussion rehabilitation team. While the majority of participants were able to recognize signs and symptoms of concussion, nearly 20% felt that they lacked the training necessary to be a part of an academic rehabilitation team for a concussed student. This finding supports the need for specific education of school nurses regarding concussion management in the academic setting.
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Concussive symptoms, both physical and cognitive, have direct and indirect effects on learning in school.15-17,23 Strategies to address graded return to academics include pain control, reduced exposure to light and sound, early dismissal from class to avoid crowded hallways, and reduced exposure to computers and videos. In addition, allowing for extra time for assignments and testing, postponing standardized testing, and having a note taker or scribe for the student may also be helpful for academic rehabilitation.15 Only 48% of school nurses in our survey correctly recognized all possible listed strategies to help a concussed student in the school setting. This emphasizes need for school nurse education about these strategies in order to advocate for their concussed students and the need for reassessment of students’ progress regularly. The single largest barrier identified to facilitation of school nurses’ leadership in academic rehabilitation is inadequate communication with the students’ other medical providers. While the diagnosis of concussion may occur at many points in a student’s care—from the sideline athletic trainer to the emergency department to the primary care physician’s office—the respondents to this survey clearly felt that this information was not being adequately relayed to the school academic team in a useful or timely manner. They commented that the lack of formalized guidelines for academic rehabilitation in the absence of specific instructions from the treating physician is detrimental to providing a unified approach for successfully returning students to the classroom. Indeed, one prior study found that only 11% of pediatric primary care providers provided written cognitive rest recommendations to patients following a diagnosis of concussion.24 Further complicating the management plan, there remains a lack of uniformity regarding how specifically to prescribe cognitive rest, and little scientific evidence for when and how much rest is necessary, which translates into little to no guidance for parents and nurses in the school setting. The general recommendation for “cognitive rest” may be difficult to implement practically. Compared to other clinical entities—in which recovery may be more accurately and objectively measured—it is often a challenge to provide an individualized concussion management plan needed for each patient. Furthermore, concussion does not have reliable prognostic indicators, making it difficult to estimate an individual’s recovery time or trajectory. While no formal policy for “return to learn” exists, the individualized approach to each patient can be guided by protocols that direct all members of the care team during a student’s recovery. There is increasing evidence that students benefit from a stepwise return-to-learn approach that mirrors return-to-play protocols.25-27 Using standardized
symptom monitoring tools, the goal is to find an appropriate level of cognitive exertion that does not exacerbate symptoms or cause reemergence of resolved symptoms. The plan, directed from the medical home and communicated to and enacted by the academic rehabilitation team, should start with cognitive rest and slowly advance to a full return-to-school activities. The AAP recommends that students should be able to tolerate 30 to 45 minutes of cognitive activity without emergence of concussive symptoms prior to returning students to the classroom.15 Only 13% of school nurses in our study were able to correctly identify this recommendation, which is an important first step in successful return to learning for concussed students. Finally, our study highlights one area for potential quality improvement at a legislative or policy level. Though all 50 states and the District of Columbia have enacted laws regarding returning concussed students to athletics, at the time of this study, no state in New England had a policy in place for returning students to academics, a fact of which most school nurses surveyed were unaware. Respondents commented on the need for a uniform policy and modes of communication between medical providers and school teams to replace the varied and often confusing health forms and discharge instructions currently in place. Local or regional concussion experts may be of invaluable assistance in directing or consulting on development of these policies, partnering with primary care physicians, emergency providers, school medical and academic teams, as well as local and state policymakers to provide up-to-date and uniform recommendations.
Limitations Our study did have limitations that must be considered. The chosen sampling frame, attendees of the annual New England School Nurses conference, is a regional sample and may not be representative of all school nurses in the United States. However, we do not anticipate any differences in concussion knowledge in New England compared to the nation due to relatively equivalent dissemination of concussion education and legislation. Additionally, the sample may be biased by including only those nurses motivated and able to receive continuing education in a conference setting. Therefore, assuming that our sample of school nurses may have more education than those not surveyed, our results may overestimate general school nurse knowledge of concussion. Finally, although the questionnaire was reviewed by expert panels and piloted prior to distribution, language about attitudes and comfort level may have been subject to varied interpretation.
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Conclusion
References
School nurses play a dynamic role in the care of concussed students. They are called on to be leaders or members of the school academic team for concussion rehabilitation, acting as both educators to school administration and faculty, as well as advocates for students. There has been limited focus on preparing school nurses for this responsibility, and 1 in 5 school nurses in our survey did not feel comfortable with this role. In order to empower those closest to students, future educational and legislative efforts should focus on school nurses. At the local level, concussion experts and programs should partner with primary care physicians and school physicians to develop uniform recommendations and forms to aid school nurses directing students’ return to the classroom. Physicians should provide every child diagnosed with concussion with written return-to-learn and return-to-play protocols to be discussed with the school academic team. On a larger scale, this study and others focusing on academic rehabilitation of concussed students are starting points for developing more effective “return-to-learn” plans. By identifying specific gaps in knowledge and challenges at the school level, these results can inform policymakers about the importance of including school nurses in legislation and mandated training. A comprehensive team approach to concussion management should facilitate better outcomes for students with concussion, including a quicker and more successful return to academics.
1. Bakhos LL, Lockhart GR, Myers R, Linakis JG. Emergency department visits for concussion in young child athletes. Pediatrics. 2010;126:e550-e556. 2. Meehan WP 3rd, Mannix R. Pediatric concussions in United States emergency departments in the years 2002 to 2006. J Pediatr. 2010;157:889-893. 3. McCrory P, Meeuwisse WH, Aubry M, et al Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;47:250-258. 4. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train. 2001;36:228-235. 5. Grady MF, Master CL, Gioia GA. Concussion pathophysiology: rationale for physical and cognitive rest. Pediatr Ann. 2012;41:377-382. 6. Halstead ME, Walter KD. American Academy of Pediatrics. Clinical report—sport-related concussion in children and adolescents. Pediatrics. 2010;126:597-615. 7. Howell D, Osternig L, Van Donkelaar P, Mayr U, Chou LS. Effects of concussion on attention and executive function in adolescents. Med Sci Sports Exerc. 2013;45: 1030-1037. 8. Harmon KG, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Clin J Sport Med. 2013;23:1-18. 9. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Athl Train. 2009;47:434-448. 10. Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collins MW, Meehan WP 3rd. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014;133:e299-e304. 11. Moser RS, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. J Pediatr. 2012;161:922-926. 12. de Kruijk JR, Leffers P, Meerhoff S, Rutten J, Twijnstra A. Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg Psychiatry. 2002;73:167-172. 13. Gibson S, Nigrovic LE, O’Brien M, Meehan WP 3rd. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj. 2013;27:839-842. 14. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135: 213-223. 15. Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K. Returning to learning following a concussion. Pediatrics. 2013;132:948-957. 16. Sady MD, Vaughan CG, Gioia GA. School and the concussed youth: recommendations for concussion education and management. Phys Med Rehabil Clin N Am. 2011;22:701-719. 17. McGrath N. Supporting the student-athlete’s return to the classroom after a sport-related concussion. J Athl Train. 2010;45:492-498.
Acknowledgments We thank the school nurses from the New England School Nurse Association who participated in this study.
Author Contributions RW and CM conceptualized and designed the study, designed the data collection instrument, coordinated and supervised data collection, carried out initial analyses and interpretation, and drafted the original manuscript. MC, SA and EJ assisted with study design, reviewed and revised the data collection instrument and reviewed the manuscript. All authors approved the final manuscript as submitted
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding was provided through a seed grant from the University Emergency Medicine Foundation of Providence, RI.
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18. 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. 19. Piebes SK, Gourley M, Valovich McLeod TC. Caring for student-athletes following a concussion. J Sch Nurs. 2009;25:270-281. 20. Wang LY, Vernon-Smiley M, Gapinski MA, Desisto M, Maughan E, Sheetz A. Cost-benefit study of school nursing services. JAMA Pediatr. 2014;168:642-648. 21. Ohio Department of Health. 2008 School Nurse Survey fact sheet. http://www.odh.ohio.gov/~/media/ODH/ ASSETS/Files/chss/school%20nursing/2008snsurvey. ashx. Accessed June 12, 2015. 22. Bergren MD, Monsalve L. The 2011 NASN Membership Survey: developing and providing leadership to advance school nursing practice. NASN Sch Nurse. 2012;27(1): 36-41.
23. McAvoy K. REAP the benefits of good concussion management. http://files.leagueathletics.com/Text/Documents/ 3365/28606.pdf. Accessed June 12, 2015. 24. Arbogast KB, McGinley AD, Master CL, Grady MF, Robinson RL, Zonfrillo MR. Cognitive rest and schoolbased recommendations following pediatric concussion: the need for primary care support tools. Clin Pediatr. 2013;52:397-402. 25. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008;43:265-274. 26. Gioia GA, Vaughan C, Reesman J, et al. Characterizing post-concussive exertional effects in the child and adolescent. J Int Neuropsychol Soc. 2010;16(suppl 1):178. 27. Lovell MR, Pardini JE, Welling J, et al. Functional brain abnormalities are related to clinical recovery and time to return-to-play in athletes. Neurosurgery. 2007;61:352-359.
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