Return to School Management Guidlines
 

Below is probably the best article that I found about returning to school.


Adolescent Concussions—Management Guidelines for Schools

For those that have dealt with this for years, I have a question regarding headaches. If they say to not return to sports/school until headaches have resolved and it's been 5 months of constant headaches - do you just keep waiting? When do you say you've rested long enough and it's time to try to move on? (My daughter did have a week with no headaches and then they came back. :( )

This article is probably the most complete I has seen. It misses one very important point.

It is of great value to understand and define the symptoms. The general symptoms can be journaled first. As a pattern of symptoms become evident, they can start to be tracked individually. Such symptoms would include:

Physical symptooms:
headaches,
dizziness,
nausea,
sleepiness/drowsiness

Emotional/psychological symptoms:
anxiety,
depression,
outbursts of anger
emotional lability/crying from minimal stimulation

Cognitive symptoms:
memory struggles
multi-tasking difficulties
decreased digit span
multi-step processing difficulties
visual overload / to much visual stimulation to process
sensitive to bright lights
auditory overload / too many sounds to process
short focus / attention span
zoning out / absence seizure
difficulties remembering / recognizing time sequencing / passage of time

Motor control symptoms
fine motor control
difficulty with fine motor control/writing-printing
shaking or tremors
gross motor control
clumsiness
awkward walking gait

This is a non-professional list but is representative of many of the symptoms experienced by a PCS subject.

Once the symptoms are identified individually, daily tasks can be moderated to accommodate the more problem-some symptoms.

It is very helpful to break down the symptoms to reduce the chaotic frustration with daily challenges. Three symptoms together can cause serious frustration. It is easier to look at each symptom individually

For example, clumsiness or awkward walking gait can be accommodated by stopping at a stair case and focusing on the task of walking up or down the stairs. This might mean stopping a conversation, finding and grabbing a hand-rail, etc. The idea is based on the need to "stop and think."

Reading a book or more likely reading a set of instructions will likely require this "stop to think" process.

I have a motor difficulty that requires that I hesitate before I get up from a sitting position. It is sort of like I need to get my balance or orientation, take a breath and then stand up. It I attempt to do it too quickly, I tend to stumble or lose my balance.

The same is true for many complex though needs. I need to stop (stop walking, thinking about something else, turn off a radio, reduce any distractions), focus on the new topic, and try to resolve the thought.

When these symptoms are understood, the reintroduction into a normal days activities is based on the level of the different symptoms. Motor control may be doing well but cognitive thought issues may be a struggle. The day is moderated accordingly.

Feel free to add any symptoms to my list. I am sure others have a few more to add.

With this understanding of symptoms, activities during recovery can be individually moderated rather than limited completely as mentioned in the article.

Great article (where the heck was that 7 months ago???). I'm forwarding it to my daughter's school counselor for future reference.

I was suprised at the term "complex concussion" vs. post concussion syndrome. Our neuro used that term but I didn't realize it had the same meaning as PCS. I agree with Mark that their list of symptoms was limited. However it is the best description I've seen aimed at the high school administration population.

If going to movies or exercising, for example, cause symptoms then you can wait awhile and try again later. That much we can figure out by journaling.

But other things are harder to figure out. Was it the bright, sunny day, or sitting through an hour of class that caused the headache? Or was it just a routine brain-healing headache? From what I can tell these headaches can come along for no reason whatsoever. Compound that with monkeying around with medication that may or may not cause headaches itself and you've got a serious puzzle to solve.

At 5 months would it be reasonable to think she is past the point of second impact syndrome?

Nancy: I'm sorry to hear your daughter's headaches came back after last week. Just when you get to thinking, "we're getting there...we're improving" there's a big WHAMO to set you back. In our experience those WHAMOs are getting further and further apart. They do make you feel like a flake, though. Your friends and family and school administration just heard you say last week that things were getting better and now she can't come to school. It's a lot longer and more complicated healing process than I think either of us has fully realized at this point.

One more thing that complicates identifying triggers...we are relying on 15-year-old girls for our information. Here is how our conversations go:

Her: My head hurts.
Me: I'm sorry. When did it start?
Her: I don't know...maybe 3rd hour.
Me: Were you reading, or...
Her: I'm fine.
Me: Did it hurt all day? (silence) Or was it one then and one now? (silence) Do you want some Tylenol? (silence)
Her: Guess what Matt did today at school?

Once in awhile, like maybe once every two weeks, my daughter will concede to a full inventory of how many symptoms she's having, what might be making them worse or better, etc. I thinks she's pretty honest and open during those inventories so I try not to get freaked out by the short conversations.

It took me a LONG time to find this article. I found a version of it posted on an school in California website and then hunted and found the original source. I too sent it to my daughter's school. It was really an eye opener for them and helped understand the situation better. They were already supportive and now they are even more supportive.


I couldn't agree more! I felt like a TOTAL flake when she didn't make it to school earlier this week. My friends that have had kids with concussions - remind me that everything is baby steps and to not get discouraged.

Honestly I don't think there is anytime that second concussions don't happen.

Sometimes it is just something folks have to work with.

It also takes medication at times, and changes of medication.

Donna

PCSLearner and other,

Second Impact Syndrome is more a diagnosis than a risk. By that I mean, after a second impact that causes serious problems, it can be diagnosed as Second Impact Syndrome. There is nothing that helps with understanding when Second Impact Syndrome becomes a non-risk.

At five months, common logic would suggest that the risk is low, but Post Concussion Syndrome does not follow any common logic. The issue that needs to be considered is simple.

There are two risks after a concussion. Second Impact Syndrome, that can cause life threatening consequences, and Multiple Impact Syndrome, that can cause life long consequences.

Second Impact Syndrome is a rare occurrence.
Multiple Impact Syndrome is not rare at all.

I suffer from Multiple Impact Syndrome. My first few impacts were the result of chance (falling down stairs at 8 years old, horrible bike fall at 10 years old, assaulted by a bully at 11 years old) A life changing impact as a high school sophomore was the result of lack of understanding the risk of heading a soccer ball.

Plain and simple, I had no idea that playing soccer and heading the ball put me at risk. Of the thirteen or so memorable concussions I have suffered, only that one was the result of putting myself at risk, even if unknowingly.

Most of the others were very mild concussions with no immediate symptoms. The symptoms did not become evident until days or weeks later. I knew I bumped my head at the time, I just did not recognize any immediate symptoms.

So, to make this longer post end, the answer is that you can never let your guard down. Your child will always be at risk of a second impact, either of life threatening or life long consequences.

The greatest risk is from those impacts with a rotational force. This would be a punch to eh chin in boxing, a bad tackle in football, an elbow to the chin in basketball, a helmet glancing pitch in baseball, or a angled header in soccer.

I have commented many times about the weakness in systems like the ImPACT test or CNS Vital Signs that test current brain function but not current brain durability.