543328
research-article2014
NASXXX10.1177/1942602X14543328NASN School NurseNASN School Nurse
Healthy Lifestyles
Managing Concussion in the School Setting Tamara C. Valovich McLeod, PhD, ATC, FNATA Concussion is a significant injury that can occur in physical education, during recreational activities, and during sports. School nurses should be included as an integral member of the concussion management team and assist with education, evaluation, and management of a concussed student. Recent and updated sport-related concussion management recommendations from the National Athletic Trainers’ Association Research and Education Foundation as published in the March 2014 Journal of Athletic Training are reviewed to provide an understanding of best practices for concussion management in the school setting. Keywords: mild traumatic brain injury; physical activity; assessment; sports
C
hildren and adolescents participating in physical education classes, recreational activities, and sports are all at risk for sustaining a concussion. In fact, the Centers for Disease Control and Prevention (CDC) estimates that the number of reported and unreported concussions, from organized sports and recreation participation, could be as high as 3.8 million injuries annually (Langlois, Rutland-Brown, & Wald, 2006). Between 2001 and 2009, the number of patients reporting to emergency departments for non-fatal traumatic brain injuries from sport or recreational activity increased 62% (CDC, 2011), highlighting the need for all medical providers to be current in
232 NASN School Nurse | September 2014
regard to concussion diagnosis and management. The National Athletic Trainers’ Association (NATA) statement adopted the definition of concussion that describes the injury as a “traumatic alteration in mental status that may or may not involve loss of consciousness” (American Academy of Neurology, 1997) and is often considered to be a subset of the mild traumatic brain injury spectrum that is usually self-limited in duration (Harmon et al., 2013). Concussive injuries result in functional deficits in a variety of domains but do not result in structural injury to the brain, which is why the overwhelming majority of concussions are negative on standard neuroimaging, such as computed tomography scans and magnetic resonance imaging. While concussions tend to be most often associated with participation in contact sports, such as football, it is important to note that concussions can occur in soccer, cheerleading, snow skiing, skateboarding, basketball, as well as other playground activities often enjoyed during recess. Therefore, it is important for the school nurse to be able to identify, evaluate, and collaboratively manage concussions that occur in the school setting. Recently, the National Athletic Trainers’ Association Research and Education Foundation released the National Athletic Trainers’ Association Position Statement: Management of Sport Concussion (Broglio et al., 2014), published in the March 2014 issue of the
Journal of Athletic Training, which may serve as a valuable resource for the school nurse. The NATA statement (Broglio et al., 2014) is an update to the original statement published in 2004 (Guskiewicz et al., 2004) and provides recommendations for clinical practice in the areas of (1) education and prevention, (2) documentation and legal aspects, (3) evaluation and return-to-play, and (4) other considerations. The authors of the statement identified 46 clinical practice recommendations, which were then graded according to the quality of evidence through the Strength of Recommendation Taxonomy. A summary of the key areas of importance for the school nurse are now discussed in greater detail.
Education and Prevention The school nurse should assist in providing education to school personnel on the recognition and appropriate management of a concussed student. This may include educating administrators, other concussion team members, coaches, parents, and others on concussion prevention, cause, recognition and referral, physical and cognitive restrictions for concussed athletes, return-to-play protocols, and ramifications of improper concussion management. It is important for the school nurse to highlight that concussions do not require the student to lose consciousness and that concussions can happen on the
DOI: 10.1177/1942602X14543328 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. Downloaded from nas.sagepub.com at East Tennessee State University on June 18, 2015 © 2014 The Author(s)
Table 1. Self-Report Symptoms Associated With Concussion Somatic-Physical
Cognitive
Emotional-Affective
Sleep-Related
Headache
Feeling mentally foggy
Irritability
Trouble falling asleep
Pressure in head
Feeling slowed down
Sadness
Drowsiness
Dizziness
Difficulty concentrating
Feeling more emotional
Sleeping more or less than usual
Neck pain
Difficulty remembering
Nervousness
Nausea or vomiting
Vision problems
Balance problems
Sensitivity to light
Sensitivity to noise
playground, on the sports field, or in the gymnasium. Proper terminology should be presented, using terms such as concussion or traumatic brain injury, as opposed to colloquial terms such as “ding” or “bell ringer,” which minimize the injury severity. A review of the concussion plan with physical education teachers and coaches should also occur.
school nurse should document the student’s evaluation and communicate the findings to the parents and appropriate medical and school personnel. Over the duration of the student’s recovery, follow-up evaluations should also be documented and communicated with other concussion team members.
Documentation and Legal Aspects
Evaluation and Return to School and Activity
To reduce the risk of legal action, all schools should develop and implement an emergency action plan (Rains & Robinson, 2012) and concussion management plan (Broglio et al., 2014). The school nurse should be an integral member of the team developing these plans, along with the athletic trainer, medical director, and other school and health care personnel, as available. The plan should include appropriate reference to the concussion laws of the state, as well as policies from the state interscholastic association and school district. Following a concussion, the school nurse and other concussion team members should follow the plan and evaluate the student in a systematic manner. A decision should then be made to immediately refer to the emergency department, call for parental pick-up, or monitor the student at the school. The
Concussion is diagnosed following a thorough evaluation, and the diagnosis is based primarily off the mechanism of injury and the clinical presentation of symptoms. Most often, concussed patients will present with one or more of the symptoms presented in Table 1 and can also have impairments in cognitive function (e.g., memory, processing speed, attention) and motor control (e.g., balance). The clinical nature of the diagnosis and the inability for imaging to assist in the diagnosis results in the need for adjunct measures of assessment to evaluate for the aforementioned deficits in cognition and balance. Many of these tools are commonly used in professional, collegiate, and high school sports; however, their use is less common in community sports, middle schools, and elementary schools, especially when an athletic trainer is not available as part of
the on-site medical team. Table 2 provides an overview of the adjunct of assessment tools. The initial evaluation of a student with a suspected concussion should include a thorough clinical examination that includes injury history, observation, oculomotor exam, palpation for associated injuries, and tests of mental status (e.g., digits backwards, word memory) and motor control (e.g., single-leg balance). If a concussion is suspected by the school nurse, the student should be removed from the event and should remain out of physical activity for the remainder of the day. Following the clinical exam, to rule out red flags for emergent referral for a suspected intracranial bleed, the nurse can administer a graded symptom scale to obtain a complete picture of the symptoms that the student is experiencing. The student should then follow up with the athletic trainer or the student’s primary care provider for additional examination. The school nurse may be involved in follow-up examinations to evaluate self-report symptom status on a daily basis until symptoms resolve. The appropriate management of the concussed student is collaborative and should include frequent communication among all members of the concussion management team.
Downloaded from nas.sagepub.com at East Tennessee State University on June 18, 2015
September 2014 | NASN School Nurse 233
Table 2. Adjunct Assessment Tools for Concussion Domain
Assessment
Example Tools
Self-report symptoms
Current and resolving self-report
•• Graded symptom scale or checklist •• Sport Concussion Assessment Tool-3 •• Acute Concussion Examination (ACE)
Mental status
Level of consciousness, attention, orientation, concentration
•• Standardized Assessment of Concussion •• Sport Concussion Assessment Tool-3
Oculomotor exam
Eye movements
•• Clinical assessment of smooth pursuits, saccades, nystagmus, pupillary reflex •• King-Devick Test
Motor control
Balance and coordination
•• Balance Error Scoring System •• Computerized posturography
Cognitive function
Immediate and delayed memory, processing speed, reaction time
•• •• •• •• •• ••
In some instances, the symptoms of the concussion warrant the student to remain home from school or to attend school with temporary academic adjustments to the student’s school plan. School absence or academic adjustments allow additional time for cognitive rest, which may assist recovery from the concussion (Valovich McLeod & Gioia, 2010). In many of these cases, the school nurse may be a key member of the concussion management team overseeing any academic adjustments (Piebes, Gourley, & Valovich McLeod, 2009). The prescription of academic adjustments is a collaborative effort between the members of the concussion management team and can include allowing rest breaks during the day, allowing additional time for assignments, limiting computer time, wearing sunglasses, avoiding noisy areas, and shortening the school day (Halstead et al., 2013). Once symptoms have resolved and the student can tolerate a full day of school, a return to physical activity progression may be implemented, which is often supervised by the athletic trainer or physician. During this return-to-activity progression, the student is progressively challenged through light exertion,
234 NASN School Nurse | September 2014
Pencil-and-paper tests (with neuropsychologist) Immediate Post-concussion Assessment and Cognitive Test (ImPACT) Axon Sports Headminders Concussion Resolution Index Concussion Vital Signs Automated Neuropsychological Assessment Metrics (ANAM)
sport-specific activity, non-contact activity, and finally full activity to determine if the increase in activity results in the return of any symptoms.
Home Care Any concussed student and his or her parent should be provided written instructions that identify red flags that warrant immediate referral, substances to avoid, appropriate nutrition, and the schedule for follow-up evaluations. This form should be developed by the directing physician, in conjunction with the other concussion management team members. The school nurse, along with the athletic trainer, should review the instructions with the parents and also discuss best practices for concussion recovery, which includes both physical and cognitive rest. Communication of the concussion and the management plan should also be provided to school administrators, the medical director, counselors, and teachers so all are aware of the student’s injury and the recommendations to aid recovery.
Role of the School Nurse As a primary on-site health care provider in the school setting, school
nurses are integral in managing the collaboration between a variety of health care and school personnel, including the school’s athletic trainer, in order to facilitate the management of a concussed student. This role may include providing education for other school personnel, administering a thorough evaluation of suspected injuries, appropriate referral, and collaborative management, including the implementation of academic adjustments. Since there have been significant advances in the area of concussion management, the school nurse should aim to stay current by understanding the most recent recommendations for managing concussion in the school setting. ■
Editor’s Note School nurses may access NASN’s position statement focusing on the role of the school nurse at the following link: http://www.nasn.org/PolicyAdvocacy/ PositionPapersandReports/ NASNPositionStatementsFullView/ tabid/462/ArticleId/218/ Concussions-The-Role-of-the-SchoolNurse-Adopted-January-2012
Downloaded from nas.sagepub.com at East Tennessee State University on June 18, 2015
References American Academy of Neurology. (1997). Practice parameter: The management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology, 48(3), 581-585. Broglio, S. P., Cantu, R. C., Gioia, G. A., Guskiewicz, K. M., Kutcher, J., Palm, M., & McLeod, T. C. (2014). National Athletic Trainers’ Association position statement: Management of sport concussion. Journal of Athletic Training. doi:10.4085/1062-605049.1.07 Centers for Disease Control and Prevention. (2011). Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged < 19 years, United States, 2001-2009. Morbidity and Mortality Weekly Report, 60(39), 1337-1342. Guskiewicz, K. M., Bruce, S. L., Cantu, R. C., Ferrara, M. S., Kelly, J. P., McCrea, M., . . . Valovich McLeod, T. C. (2004). National Athletic Trainers’ Association position statement: Management of sport-related concussion. Journal of Athletic Training, 39(3), 280-297.
Halstead, M. E., McAvoy, K., Devore, C. D., Carl, R., Lee, M., & Logan, K. (2013). Returning to learning following a concussion. Pediatrics, 132(5), 948-957. doi:10.1542/peds.20132867peds.2013-2867 Harmon, K. G., Drezner, J. A., Gammons, M., Guskiewicz, K. M., Halstead, M., Herring, S. A., . . . Roberts, W. O. (2013). American Medical Society for Sports Medicine position statement: Concussion in sport. British Journal of Sports Medicine, 47(1), 15-26. doi:10.1136/bjsports-2012-091941 Langlois, J. A., Rutland-Brown, W., & Wald, M. M. (2006). The epidemiology and impact of traumatic brain injury: A brief overview. The Journal of Head Trauma Rehabilitation, 21(5), 375-378. Piebes, S. K., Gourley, M., & Valovich McLeod, T. C. (2009). Caring for studentathletes following a concussion. The Journal of School Nursing, 25(4), 270-281. doi:10.1177/1059840509339782 Rains, C. A., & Robinson, B. (2012). School nurses and athletic trainers team up on emergency planning. NASN School Nurse, 27(3), 136-142.
Valovich McLeod, T. C., & Gioia, G. A. (2010). Cognitive rest: The often neglected aspect of concussion management. Athletic Therapy Today, 15(2), 1-3.
Tamara C. Valovich McLeod, PhD, ATC, FNATA Professor and Director, Athletic Training Program A.T. Still University Mesa, AZ Dr. McLeod’s primary research interest is studying pediatric sport-related concussion, with emphasis on quality of life and return to school. She is a co-author on the recently published National Athletic Trainers’ Association position statement on managing sport concussion.
Downloaded from nas.sagepub.com at East Tennessee State University on June 18, 2015
September 2014 | NASN School Nurse 235
research-article2014
NASXXX10.1177/1942602X14543328NASN School NurseNASN School Nurse
Healthy Lifestyles
Managing Concussion in the School Setting Tamara C. Valovich McLeod, PhD, ATC, FNATA Concussion is a significant injury that can occur in physical education, during recreational activities, and during sports. School nurses should be included as an integral member of the concussion management team and assist with education, evaluation, and management of a concussed student. Recent and updated sport-related concussion management recommendations from the National Athletic Trainers’ Association Research and Education Foundation as published in the March 2014 Journal of Athletic Training are reviewed to provide an understanding of best practices for concussion management in the school setting. Keywords: mild traumatic brain injury; physical activity; assessment; sports
C
hildren and adolescents participating in physical education classes, recreational activities, and sports are all at risk for sustaining a concussion. In fact, the Centers for Disease Control and Prevention (CDC) estimates that the number of reported and unreported concussions, from organized sports and recreation participation, could be as high as 3.8 million injuries annually (Langlois, Rutland-Brown, & Wald, 2006). Between 2001 and 2009, the number of patients reporting to emergency departments for non-fatal traumatic brain injuries from sport or recreational activity increased 62% (CDC, 2011), highlighting the need for all medical providers to be current in
232 NASN School Nurse | September 2014
regard to concussion diagnosis and management. The National Athletic Trainers’ Association (NATA) statement adopted the definition of concussion that describes the injury as a “traumatic alteration in mental status that may or may not involve loss of consciousness” (American Academy of Neurology, 1997) and is often considered to be a subset of the mild traumatic brain injury spectrum that is usually self-limited in duration (Harmon et al., 2013). Concussive injuries result in functional deficits in a variety of domains but do not result in structural injury to the brain, which is why the overwhelming majority of concussions are negative on standard neuroimaging, such as computed tomography scans and magnetic resonance imaging. While concussions tend to be most often associated with participation in contact sports, such as football, it is important to note that concussions can occur in soccer, cheerleading, snow skiing, skateboarding, basketball, as well as other playground activities often enjoyed during recess. Therefore, it is important for the school nurse to be able to identify, evaluate, and collaboratively manage concussions that occur in the school setting. Recently, the National Athletic Trainers’ Association Research and Education Foundation released the National Athletic Trainers’ Association Position Statement: Management of Sport Concussion (Broglio et al., 2014), published in the March 2014 issue of the
Journal of Athletic Training, which may serve as a valuable resource for the school nurse. The NATA statement (Broglio et al., 2014) is an update to the original statement published in 2004 (Guskiewicz et al., 2004) and provides recommendations for clinical practice in the areas of (1) education and prevention, (2) documentation and legal aspects, (3) evaluation and return-to-play, and (4) other considerations. The authors of the statement identified 46 clinical practice recommendations, which were then graded according to the quality of evidence through the Strength of Recommendation Taxonomy. A summary of the key areas of importance for the school nurse are now discussed in greater detail.
Education and Prevention The school nurse should assist in providing education to school personnel on the recognition and appropriate management of a concussed student. This may include educating administrators, other concussion team members, coaches, parents, and others on concussion prevention, cause, recognition and referral, physical and cognitive restrictions for concussed athletes, return-to-play protocols, and ramifications of improper concussion management. It is important for the school nurse to highlight that concussions do not require the student to lose consciousness and that concussions can happen on the
DOI: 10.1177/1942602X14543328 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. Downloaded from nas.sagepub.com at East Tennessee State University on June 18, 2015 © 2014 The Author(s)
Table 1. Self-Report Symptoms Associated With Concussion Somatic-Physical
Cognitive
Emotional-Affective
Sleep-Related
Headache
Feeling mentally foggy
Irritability
Trouble falling asleep
Pressure in head
Feeling slowed down
Sadness
Drowsiness
Dizziness
Difficulty concentrating
Feeling more emotional
Sleeping more or less than usual
Neck pain
Difficulty remembering
Nervousness
Nausea or vomiting
Vision problems
Balance problems
Sensitivity to light
Sensitivity to noise
playground, on the sports field, or in the gymnasium. Proper terminology should be presented, using terms such as concussion or traumatic brain injury, as opposed to colloquial terms such as “ding” or “bell ringer,” which minimize the injury severity. A review of the concussion plan with physical education teachers and coaches should also occur.
school nurse should document the student’s evaluation and communicate the findings to the parents and appropriate medical and school personnel. Over the duration of the student’s recovery, follow-up evaluations should also be documented and communicated with other concussion team members.
Documentation and Legal Aspects
Evaluation and Return to School and Activity
To reduce the risk of legal action, all schools should develop and implement an emergency action plan (Rains & Robinson, 2012) and concussion management plan (Broglio et al., 2014). The school nurse should be an integral member of the team developing these plans, along with the athletic trainer, medical director, and other school and health care personnel, as available. The plan should include appropriate reference to the concussion laws of the state, as well as policies from the state interscholastic association and school district. Following a concussion, the school nurse and other concussion team members should follow the plan and evaluate the student in a systematic manner. A decision should then be made to immediately refer to the emergency department, call for parental pick-up, or monitor the student at the school. The
Concussion is diagnosed following a thorough evaluation, and the diagnosis is based primarily off the mechanism of injury and the clinical presentation of symptoms. Most often, concussed patients will present with one or more of the symptoms presented in Table 1 and can also have impairments in cognitive function (e.g., memory, processing speed, attention) and motor control (e.g., balance). The clinical nature of the diagnosis and the inability for imaging to assist in the diagnosis results in the need for adjunct measures of assessment to evaluate for the aforementioned deficits in cognition and balance. Many of these tools are commonly used in professional, collegiate, and high school sports; however, their use is less common in community sports, middle schools, and elementary schools, especially when an athletic trainer is not available as part of
the on-site medical team. Table 2 provides an overview of the adjunct of assessment tools. The initial evaluation of a student with a suspected concussion should include a thorough clinical examination that includes injury history, observation, oculomotor exam, palpation for associated injuries, and tests of mental status (e.g., digits backwards, word memory) and motor control (e.g., single-leg balance). If a concussion is suspected by the school nurse, the student should be removed from the event and should remain out of physical activity for the remainder of the day. Following the clinical exam, to rule out red flags for emergent referral for a suspected intracranial bleed, the nurse can administer a graded symptom scale to obtain a complete picture of the symptoms that the student is experiencing. The student should then follow up with the athletic trainer or the student’s primary care provider for additional examination. The school nurse may be involved in follow-up examinations to evaluate self-report symptom status on a daily basis until symptoms resolve. The appropriate management of the concussed student is collaborative and should include frequent communication among all members of the concussion management team.
Downloaded from nas.sagepub.com at East Tennessee State University on June 18, 2015
September 2014 | NASN School Nurse 233
Table 2. Adjunct Assessment Tools for Concussion Domain
Assessment
Example Tools
Self-report symptoms
Current and resolving self-report
•• Graded symptom scale or checklist •• Sport Concussion Assessment Tool-3 •• Acute Concussion Examination (ACE)
Mental status
Level of consciousness, attention, orientation, concentration
•• Standardized Assessment of Concussion •• Sport Concussion Assessment Tool-3
Oculomotor exam
Eye movements
•• Clinical assessment of smooth pursuits, saccades, nystagmus, pupillary reflex •• King-Devick Test
Motor control
Balance and coordination
•• Balance Error Scoring System •• Computerized posturography
Cognitive function
Immediate and delayed memory, processing speed, reaction time
•• •• •• •• •• ••
In some instances, the symptoms of the concussion warrant the student to remain home from school or to attend school with temporary academic adjustments to the student’s school plan. School absence or academic adjustments allow additional time for cognitive rest, which may assist recovery from the concussion (Valovich McLeod & Gioia, 2010). In many of these cases, the school nurse may be a key member of the concussion management team overseeing any academic adjustments (Piebes, Gourley, & Valovich McLeod, 2009). The prescription of academic adjustments is a collaborative effort between the members of the concussion management team and can include allowing rest breaks during the day, allowing additional time for assignments, limiting computer time, wearing sunglasses, avoiding noisy areas, and shortening the school day (Halstead et al., 2013). Once symptoms have resolved and the student can tolerate a full day of school, a return to physical activity progression may be implemented, which is often supervised by the athletic trainer or physician. During this return-to-activity progression, the student is progressively challenged through light exertion,
234 NASN School Nurse | September 2014
Pencil-and-paper tests (with neuropsychologist) Immediate Post-concussion Assessment and Cognitive Test (ImPACT) Axon Sports Headminders Concussion Resolution Index Concussion Vital Signs Automated Neuropsychological Assessment Metrics (ANAM)
sport-specific activity, non-contact activity, and finally full activity to determine if the increase in activity results in the return of any symptoms.
Home Care Any concussed student and his or her parent should be provided written instructions that identify red flags that warrant immediate referral, substances to avoid, appropriate nutrition, and the schedule for follow-up evaluations. This form should be developed by the directing physician, in conjunction with the other concussion management team members. The school nurse, along with the athletic trainer, should review the instructions with the parents and also discuss best practices for concussion recovery, which includes both physical and cognitive rest. Communication of the concussion and the management plan should also be provided to school administrators, the medical director, counselors, and teachers so all are aware of the student’s injury and the recommendations to aid recovery.
Role of the School Nurse As a primary on-site health care provider in the school setting, school
nurses are integral in managing the collaboration between a variety of health care and school personnel, including the school’s athletic trainer, in order to facilitate the management of a concussed student. This role may include providing education for other school personnel, administering a thorough evaluation of suspected injuries, appropriate referral, and collaborative management, including the implementation of academic adjustments. Since there have been significant advances in the area of concussion management, the school nurse should aim to stay current by understanding the most recent recommendations for managing concussion in the school setting. ■
Editor’s Note School nurses may access NASN’s position statement focusing on the role of the school nurse at the following link: http://www.nasn.org/PolicyAdvocacy/ PositionPapersandReports/ NASNPositionStatementsFullView/ tabid/462/ArticleId/218/ Concussions-The-Role-of-the-SchoolNurse-Adopted-January-2012
Downloaded from nas.sagepub.com at East Tennessee State University on June 18, 2015
References American Academy of Neurology. (1997). Practice parameter: The management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology, 48(3), 581-585. Broglio, S. P., Cantu, R. C., Gioia, G. A., Guskiewicz, K. M., Kutcher, J., Palm, M., & McLeod, T. C. (2014). National Athletic Trainers’ Association position statement: Management of sport concussion. Journal of Athletic Training. doi:10.4085/1062-605049.1.07 Centers for Disease Control and Prevention. (2011). Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged < 19 years, United States, 2001-2009. Morbidity and Mortality Weekly Report, 60(39), 1337-1342. Guskiewicz, K. M., Bruce, S. L., Cantu, R. C., Ferrara, M. S., Kelly, J. P., McCrea, M., . . . Valovich McLeod, T. C. (2004). National Athletic Trainers’ Association position statement: Management of sport-related concussion. Journal of Athletic Training, 39(3), 280-297.
Halstead, M. E., McAvoy, K., Devore, C. D., Carl, R., Lee, M., & Logan, K. (2013). Returning to learning following a concussion. Pediatrics, 132(5), 948-957. doi:10.1542/peds.20132867peds.2013-2867 Harmon, K. G., Drezner, J. A., Gammons, M., Guskiewicz, K. M., Halstead, M., Herring, S. A., . . . Roberts, W. O. (2013). American Medical Society for Sports Medicine position statement: Concussion in sport. British Journal of Sports Medicine, 47(1), 15-26. doi:10.1136/bjsports-2012-091941 Langlois, J. A., Rutland-Brown, W., & Wald, M. M. (2006). The epidemiology and impact of traumatic brain injury: A brief overview. The Journal of Head Trauma Rehabilitation, 21(5), 375-378. Piebes, S. K., Gourley, M., & Valovich McLeod, T. C. (2009). Caring for studentathletes following a concussion. The Journal of School Nursing, 25(4), 270-281. doi:10.1177/1059840509339782 Rains, C. A., & Robinson, B. (2012). School nurses and athletic trainers team up on emergency planning. NASN School Nurse, 27(3), 136-142.
Valovich McLeod, T. C., & Gioia, G. A. (2010). Cognitive rest: The often neglected aspect of concussion management. Athletic Therapy Today, 15(2), 1-3.
Tamara C. Valovich McLeod, PhD, ATC, FNATA Professor and Director, Athletic Training Program A.T. Still University Mesa, AZ Dr. McLeod’s primary research interest is studying pediatric sport-related concussion, with emphasis on quality of life and return to school. She is a co-author on the recently published National Athletic Trainers’ Association position statement on managing sport concussion.
Downloaded from nas.sagepub.com at East Tennessee State University on June 18, 2015
September 2014 | NASN School Nurse 235
