Return to Learn Concussion Guidelines Every Parent Should Know

When a child has a concussion, the rules for getting back to sports are laid out by state Return to Play laws. But when it comes to getting back to the classroom, the rules aren’t as clear.

A recent study in the journal Pediatrics found that only a few states have Return to Learn concussion laws, and these varied in terms of responsibility. Some of the laws were restricted to student athletes, excluding students who sustained non-sport related concussions.

“When returning a student to the classroom after a concussion, we try to balance stimulation levels and worsening of symptoms,” explains Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC Children’s. “While too much cognitive exertion can lead to headaches, problems concentrating, fatigue and trouble with emotional control, over restriction from classroom and academic activities can result in social isolation and anxiety about falling behind or lower grades that can also slow the recovery process.

return to learn
Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC Children’s.

“Returning to the classroom after a concussion optimally takes a team approach including the student, family, medical and education teams,” Dr. Koutures says. “Flexibility and creativity in paying attention to individual student needs and concerns can make this process more rewarding for all parties.”

Dr. Koutures advises the patient’s care team, including parents, to follow CHOC’s recommended six stages for returning a student to school after a concussion, including the following added guidelines:

Step-wise Return to Learn Progression

Step 1: No formal academic activity

  • Recent studies suggest that full or prolonged limitations in cognitive activity may actually delay recovery
  • In first few days after concussion, allow 15-20 minute intervals of single-task activities that do not provoke symptoms and are not excessively taxing
    • Listen to light music
    • Draw or color
    • Journal writing
    • Audiobooks
    • Passive television or movies (at home), larger screen preferred, lower volume
    • Some texting, smartphone use; want to balance maintaining key social contacts with not having symptom-flare
    • Conversations with 1-2 other people
  • Separate the 15-20 minute bursts of activity by 30-40 minutes minimum of non-cognitive activity
  • If symptoms flare before 15-20 minute limit, stop activity and try again later
  • If patient can handle 2-3 periods of 15-20 minute activity over the course of day, can consider advancing toward partial return to school

Step 2: Light academic activity

  • Attend 1-2 periods or 1-2 hours of school
  • Select consecutive classes; have child help make decision
  • No physical education or other activity classes
    • Caution with more noisy classes such as woodshop, music/band, chorus
  • Tend to avoid first class in morning to allow more sleep and arrival at school without busy parking lot and hallways
  • Main goal: be in class; no responsibility for note-taking, participating in class /responding to teacher, in-class work, homework or testing
    • Audible learning (most kids handle this better than visual learning after a concussion)
    • Should have pre-printed notes for reference or have others take notes and share
  • Sit away from louder students, windows, projectors, or other light/noise stimulation
  • Sit close to teacher
  • Allow to wear earplugs and sunglasses as needed
  • May allow brief 1-2 minute periods of putting head on desk for rest
  • May leave class early to avoid the noise and commotion of hallways during passing periods

Step 3: Increased academic activity

  • Expand day to 3-4 periods or hours per day
  • Incorporate break periods (nutrition break, lunch)
    • Have quiet place to rest
  • Recommend against assemblies or rallies due to noise stimulation
  • Continue to avoid physical education or activity classes
  • Main goal is to be in class and handle longer day; still not responsible for note-taking, participating in class/responding to teacher, in-class work or homework

Step 4: Full-time attendance

  • Full-day attendance without activity or other higher-stimulation classes
  • May expect some increased fatigue at end of school day
    • If student wants to nap after school, limit to no more than one hour
  • May start to take own notes, though helpful to have pre-printed teacher’s notes or other student notes
  • Incorporate “to do” lists with short-block (10-15 minute) work periods followed by short (5 minute) breaks
  • Break period and breaks in class (especially if block schedule) may still be needed
  • If possible, move most challenging courses to time of day when student feels the best

Step 5: Return to Majority of Academic Activities

  • Once handling full day attendance, can resume taking notes in class, verbal responses to teacher, and in-class work
  • May begin homework starting with limits to 30-60 minutes a night and priority on essential concepts that are needed for eventual testing or continuity of learning
    • Waive any projects, papers, essays or other assignments that are not required for future learning needs
    • Try to limit burden of make-up work; focus should be on those assignments that are necessary for future learning
      • Sequential classes (math, foreign languages, science) tend to be the most challenging for make-up work
    • No tests or quizzes at this stage
    • Audible learning – listen/speak responses vs. writing, dictating work, audiobooks may be more favorable at this point

Step 6: Return to Full Academic Activity

  • Full-day attendance without symptoms, fulfilling all in-class duties and completing usual homework assignments
  • Can resume tests and quizzes
    • Strongly consider waiving missed tests or quizzes
    • Combine missed tests or quizzes to allow more quick completion of make-up work
    • Allow student to take missed tests/quizzes to gain exposure/mastery of material without being graded, or only receive grade if results are in usual level of achievement
    • Assign grades at end of grading period based on level of work prior to concussion
  • May need more time for test completion
  • May need individual room placement for testing
  • May limit testing/make-up testing to one test per day
  • May allow open book, use of notes, word banks or home-based testing
  • Consider alternate forms of testing such as spoken test, or multiple choice vs. longer essay responses that might be more taxing for the student
  • Students may still benefit from more audio learning
  • Can resume physical education (with physician release) and activity courses
Learn about the CHOC Children’s Concussion Program now.

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Importance of Stretching for the Young Athlete

By Victor Araiza, physical therapy assistant at CHOC Children’s

Stretching can often take a back seat to your general exercise routine and sport-related activities, but these are an essential part of any conditioning or physical therapy program. Stretching decreases the risk of injury or re-injury and promotes wellness.

Why is stretching so important?

Stretching the right way will help improve flexibility and make it easier for you to move. Stretching properly can increase and improve motion in your joints, increase blood flow, and decrease feelings of stiffness. Other potential benefits of stretching can include reducing delayed onset muscle soreness, increasing athletic performance and reducing the risk of tendon or muscle tears.

It is important to stretch correctly and know which muscle groups you want to stretch. Often, the muscles that tend to be tight are the hamstrings, hip flexors, quadriceps, calves and chest muscles. If proper technique is used when stretching, it will help improve flexibility and increase range of motion. This will increase blood flow and decrease stiffness, in turn decreasing the risk of injury or reinjury.

When to stretch

It is recommended that you perform static stretches after exercising, engaging in strenuous physical activity or participating in an athletic event. Static stretches target specific muscles based on the position you are in with the intent to elongate just past the point of a moderate pulling sensation. The static stretch should be held in the same position for 30-60 seconds and repeated two to three times. For an athlete, it is common to perform a dynamic warm-up prior to sport related activities and static stretches after activities. The American College of Sports Medicine guidelines recommends stretching activities be done at least two days per week. It is also important to know and understand which stretches would benefit you based on your limitations and desired activity participation.

Stretching is encouraged:

  •  When range of motion is limited.
  • Prior to or after vigorous exercises.
  • As a component of your sport-specific conditioning program, team warm-up/cool down and before/after a participation in a sporting event.

When is stretching not encouraged?

  • When someone has excessive movement in their joint(s)
  • An athlete who has experienced a recent fracture
  • After sudden onset of inflammation or swelling
  • When you feel a sharp pain when attempting to stretch

 Tips on how to stretch

It is important to remember that just because you perform stretches doesn’t mean that you will never get injured. Stretching won’t prevent an overuse injury that is predominant in sports that involve the repetition of similar movement patterns. There are other important factors such as strength and endurance training, essential to reducing the risk of injury. Please consult your pediatrician for a referral to physical therapy if you and your child need assistance with an exercise and stretching program.

Learn more about rehabilitation services at CHOC.

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Olympic Medalist Turned Physical Therapist

When athletes of any caliber come to physical therapy appointments, they often struggle with emotional hurdles as big as their physical challenges. Working with an expert who understands their struggles can make it easier to cope, especially when that expert is a former Olympian.

Robin Beauregard, a physical therapist at CHOC Children’s and two-time Olympic medalist in women’s water polo, understands the physical challenges that can sometimes stand in the way of achieving athletic goals.

olympics

“Having a career in athletics helps me establish a rapport with my patients, particularly my history with sustaining and overcoming injuries,” she says. “Sincere empathy creates a stronger bond than sympathy.”

Shortly before the team was named for the Sydney Olympics in 2000, the first time women’s water polo was to be recognized as an Olympic sport, Beauregard dislocated her knee and didn’t know if a recovery was possible. Distraught but determined, she committed fully to her physical therapy plan, as well as a rigorous conditioning program, and made the team. They’d win a silver medal that year, and a bronze four years later. She was later inducted into the USA Water Polo Hall of Fame.

Beauregard’s experience with physical therapy in the midst of her Olympic career ultimately played a big role in her professional career.

“I was not the perfect patient, but it prepared me for being a physical therapist because it gave me an idea of asking only what is reasonable of my teen and young adult patients,” she says. “I really do understand their worry of not being able to get back to the top level in their sport, but also weighing the risks of not wanting to cause further or permanent injury.”

Growing up in Southern California, Beauregard loved to be outdoors and was always active. Having an older brother who was also athletic made her competitive, too. She started swimming competitively for a local club team on her fourth birthday simply because her brother swam, and she wanted to be as a good as he was. Water polo came into play just four years later, and by age 8 she joined a competitive club team.

But when she got to high school, there was no girls’ varsity team. Instead of giving up on her passion, she simply joined the boys’ team instead. Playing with the boys didn’t faze her, or them, since they’d been competing together for almost a decade by that point. When opponents made comments about playing with a girl, she channeled it into her game and used it as fuel to play even harder.

olympics

After high school, she attended UCLA to play water polo, and originally planned on becoming an orthopedic surgeon. She later changed her path to physical therapy, which would ultimately give her a different kind of interaction with patients and athletes.

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Common Little League and Softball Injuries in Children

Overuse injuries can plague athletes of all ages and sizes, and youth softball and baseball competitors are no exception, a CHOC Children’s sports medicine specialist says. Two of the most common injuries that affect youth competing in either of these sports are commonly referred to as ‘Little League Shoulder’ and ‘Little League Elbow,’ says Dr. Jonathan Minor, a CHOC pediatrician who specializes in sports injuries, injury prevention, and concussion management.

Dr. Jonathon Minor

‘Little League shoulder’ is a fracture of the growth plate in the shoulder. A warning sign is often pain that comes with throwing, without any preexisting injury. ‘Little League elbow’ is a small growth plate injury on the inside part of the elbow. Many will eventually hear or feel a ‘pop’ on the inside of the elbow, which often is a small piece of bone being pulled away from the elbow, at which time you should seek medical evaluation urgently, says Minor.

With either injury, pain tends to be gradual. Initially the shoulder or elbow may feel sore after games for players in heavy throwing positions such as pitchers, catchers or outfielders. For example, for pitchers, the shoulder or elbow may feel sore after pitching, but often after one to two weeks of continued throwing, they may experience pain during the game as well.

“Forty percent of the speed of the ball comes from the arm and shoulder, and the rest comes from the core, legs and hips,” says Minor. “Proper form is essential to preventing injuries. This also means that having strong lower body and core muscles, not just a strong upper body, is imperative. Working with a throwing mechanics coach can be very helpful at utilizing each of these different muscle groups.”

Other preventative measures include adhering to the sporting organization’s rules for pitch counts and rest requirements between pitching appearances. Athletes also should not be allowed to switch from one heavy-throwing position to another during the game, such as playing catcher after pitching for several innings. Remind your child to do a proper warm-up and cool down before and after practices and games. Consider loosening up arm muscles with a heating pad prior to practice, as tight muscles are more prone to injury.

Athletes at this age are developing their skills as well as their sense of competitiveness, but that doesn’t mean they should be playing through the pain, he adds.

Leagues often encourage players to recognize when and where their pain occurs. Consult a physical therapist or athletic trainer initially, and if basic treatments like rest, ice, and basic medication such as ibuprofen, are not helping, ask your pediatrician about a referral to a sports medicine specialist.

Since a major contributing factor to these all-too-common injuries include throwing mechanics, Minor often recommends athletes work with a physical therapy program that has experience with athletes in their chosen sport, in order to work on proper form.

Recommendations for treatment are made on a case-by-case basis says Minor, but may include rest, X-rays or other imaging, or changing positions in the game to a position less strenuous to their injury.

Since these pains are often gradual, they may get more severe as the season progresses. As playoffs commence, athletes may fear that speaking up about an injury could prevent them from participating, or result in other consequences. Encourage your young athlete to be honest about how they’re feeling, since identifying an injury and seeking treatment sooner rather than later, can allow them to return to competition earlier.

“Southern California is such a great place to live- the weather is very conducive to playing baseball and softball for twelve months out of the year. But every athlete, especially ones who throw often, should have a few months off per year to prevent overuse injuries. Try playing another sport that doesn’t involve throwing, or focus on conditioning work, particularly hips, legs and core that all too often get neglected during the season,” says Minor.

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Concussion Program Prescribes At-Home Exercises

Athletes and other adolescents with mild to severe concussions who experience symptoms such as dizziness, feeling unbalanced on their feet, blurred vision or trouble focusing on objects, may be good candidates for at-home visual and vestibular exercises recently designed by experts of the CHOC Children’s concussion program.

“Concussions are like puzzles, and every one is a little bit different,” says Dr. Jonathan Minor, a CHOC sports medicine specialist. “As many as fifty percent of concussed athletes may experience these symptoms and could benefit from these exercises that may get them back on the field or back in the classroom sooner.”

concussion exercises
Dr. Jonathan Minor models one of several at-home exercises recently designed by experts of the CHOC Children’s concussion program.

The convenient and self-explanatory exercises are ones that athletes and students can perform at home, but should only be started under the guidance of a concussion specialist, after an appropriate evaluation, and as part of an overall post-concussion treatment plan. These exercises are intended to enhance and improve a patient’s recovery from a concussion.

“Patients should be aware that beginning these exercises may stimulate some symptoms for a short period of time, such as trouble focusing, dizziness, nausea or headaches. But after just a few days of daily exercises, they may find that they can tolerate each exercise for a longer period of time,” says Minor, who is a lifetime athlete himself.

“We encourage our patients to only perform these exercises for the duration tolerated, rather than endure and push through worsening symptoms initially. Seeing a difference quickly with improved tolerance resonates especially with athletes, who are used to training and then seeing improved results.”

Download your copy of the vestibular/balance exercises and the visual concussion home exercises.

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Cheerleading Safety Tips

Cheerleading is a physically demanding sport, much like ballet or gymnastics. Sports medicine specialists at CHOC Children’s regularly treat common sports injuries like ankle sprains and tendinitis, but say athletes may be overlooking some of the more serious injuries, and ways to avoid them, according to Dr. Jonathan Minor.

Dr. Jonathon Minor

Stress fractures in the feet, shins and back, herniated discs, spinal cord and vertebral injuries, elbow and shoulder dislocations, concussions and major fractures, are some of the other potential injuries athletes, parents and  coaches should be aware of and monitor for, says Minor.

Since each member of a cheer squad plays a unique role, they’re exposed to different potentials for injury. Flyers, bases and spotters rely on one another in teamwork to safely perform stunts and poses. One slip up could mean foot coming into contact with a teammate’s head leading to a concussion, or a fall to the ground with a major injury.

Like many other sports, youth cheerleaders spend many hours each week working together and developing teamwork that depends on a sense of trust and communication in order to perform with perfection. But this can often lead to overuse injuries, says Minor. Overuse injuries are becoming more common in youth sports because increasing pressure to compete at a higher level leads athletes to specialize in one sport at a younger age, as opposed to trying other activities in their off season. Learn how to prevent overuse injuries.

Much like gymnastics, running, diving, figure skating and dance, among other sports, there is an aesthetic look that the sport cultivates, such as low body weight and a slim build. The pressure of appearance and the rewards of recognition, says Minor, can promote unhealthy eating behaviors and disorders. This can lead to broken bones, stress fractures and muscle strains because bones and muscles don’t properly recover from stress and demands. Learn more about the warning signs of eating disorders.

Although cheerleaders can suffer serious sports injuries due to the physical demands they meet that are unparalleled in other sports, safety and proper education when performing stunts, as well as communication with teammates, is paramount to preventing these injuries.

Learn more about CHOC’s sports medicine program.

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CHOC Children’s Expands Orthopaedic Services

Young athletes in Orange County now have greater access to specialized sports medicine care as a non-surgical sports medicine specialist joins the CHOC Children’s Orthopaedic Institute. Dr. Jonathan Minor specializes in ultrasound-guided injections and procedures, as well as diagnostic ultrasound evaluations, which provide improved visualization of the body tissues. The enhanced view, so to speak, along with dynamic tissue evaluation and use of selective injections can confirm the location of pain and assist with surgical decision-making.  Ultrasound-guided injections can offer a quicker recovery and may be used to avoid surgery altogether in some patients.

Dr. Jonathon Minor

Dr. Minor’s commitment to helping young athletes return to the field stems from his own lifetime experience as an athlete. As an adult, he has completed multiple marathons and Ironman triathlons, including three Long Course World Championship races with Team USA.

His passion for sports medicine was inspired by his father, an accomplished orthopaedic surgeon.

“I was moved by my dad being able to take an injury, and just like a carpenter, put it back together,” Dr. Minor said. “As a non-surgeon, I consider myself more like an architect, laying out a floor plan, and bringing together a team of providers to treat and safely return our athletes back to the sports arena.”

After medical school and residency training, he completed a non-surgical sports medicine fellowship and an additional musculoskeletal ultrasound fellowship at Boston Children’s Hospital. During his training in Boston, he served as team physician for several collegiate and high school teams, and worked closely with the Boston Ballet.

A chance to work with the expert team at CHOC and help expand the sports medicine program led Dr. Minor back to his native California. He treats everything from ankle and knee ligament sprains to overuse injuries and concussions.  Dr. Minor is working with the experts at the Orthopaedic Institute to expand the footprint of its sports medicine program with the addition of physical therapists, new regional physical therapy locations and a new orthopaedic surgeon, Dr. Jessica McMichael.

“Given the number and caliber of athletes coming out of Orange County, I am honored to be part of a growing and highly respected sports medicine program at the CHOC Children’s Orthopaedic Institute,” says Minor.

As an avid athlete, Dr. Minor is dedicated to injury prevention, particularly overuse injuries. He offers athletes of all ages the following tips to prevent sports injuries:

  • Stay committed to a progressive training program
  • In preparation for a new sport or season, make sure your body is conditioned aerobically before training with your team
  • Consistently stretch after a warm-up and again after exercise
  • With the exception of gymnasts and ice skaters, athletes should not specialize in a single sport until they are well into high school
  • While California offers a perfect climate for year-round single sport specialization, every athlete should spend 2-4 months every year outside of their primary sport; this could involve playing a sport that uses different muscle groups, or spending the time working with a personal trainer to optimize fitness and neglected muscle groups

Learn more about CHOC’s sports medicine program.

Preventing and Treating Concussions

CHOC Children’s multidisciplinary team of concussion experts can help prevent and treat concussions, as well as help patients ease back in to school and sports. Careful supervision is essential for young persons with concussions, since their brains are still developing.

In this episode of CHOC Radio, Dr. Sharief Taraman, a pediatric neurologist, Dr. Jonathan Minor, a sports medicine specialist, Jenn Ahlswede, a speech language pathologist, and Mollee Oh, a physical therapist and rehabilitation supervisor, discuss:

  • SCAT3, an assessment tool parents and coaches can use immediately after an incident occurs
  • The film “Concussion,” and how concussions affect kids and teens differently than adults
  • Recommendations for cognizant and physical rest periods after sustaining a concussion

Hear more from CHOC experts in this podcast.

CHOC Radio theme music by Pat Jacobs.

CHOC Experts Discuss Sports Injury Prevention

Early specialization and lack of diversity are more common in young athletes today and can increase the chances of injury, two CHOC Children’s experts tell “American Health Journal.”

A lack of rest and chronic repetitive stress can lead to overuse and injuries, say Dr. John Schlechter, a CHOC orthopedic surgeon, and Mollee Smith, a physical therapist at CHOC. Following an injury, CHOC clinicians work with both the child and the family to ensure proper healing and future injury prevention.

Learn more about sports injury prevention in “American Health Journal,” a television program that airs on PBS and other national network affiliates that reach more than 40 million households.

Each 30-minute episode features six segments with a diverse range of medical specialists discussing a full spectrum of health topics. For more information, visit www.discoverhealth.tv.

John Schlechter, D.O., attended medical school at the New York College of Osteopathic Medicine at the New York Institute of Technology. He completed his orthopedic surgery residency at Riverside County Regional Medical Center. He completed a pediatric orthopedic and scoliosis fellowship at Children’s Hospital San Diego as well as a post-fellowship preceptorship in sports medicine and arthroscopy at the Orthopedic Specialty Institute in Orange, Calif.

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The Importance of Heart Screenings for Athletes

Parents of young athletes should talk to their pediatrician about getting pre-participation sports physicals that include heart  screenings.

After all, sudden cardiac death is 2 ½ times more likely to occur in young athletes than in non-athletes. Hypertrophic cardiomyopathy, the most common cause of sudden cardiac death in young athletes, occurs in one of every 500 people.

Young athletes are encouraged to have a physical that includes a general exam, a complete health history and family history, a 12-lead EKG screening and, for athletes with an abnormal EKG or family history, an echocardiogram. An exercise test may also be recommended.

To address the growing rate of sudden cardiac arrest in young athletes, CHOC Children’s Sports Medicine collaborates with the CHOC Children’s Heart Institute to offer the Life-Threatening Events Associated with Pediatric Sports (LEAPS) program. CHOC cardiologists work one-on-one with area schools on several fronts:

• Educate coaches and staff about heart conditions.
• Offer electrocardiogram (EKG) screenings to identify athletes at risk.
• Encourage CPR training and the installation of automatic external defibrillators (AEDs) near gyms, fields and other sports facilities.

CHOC also hosts a regular conference for Orange County school board members, high school coaches, school nurses, community pediatricians and parents who want to lower the incidence of sudden cardiac death in local teenage athletes.

To learn more, contact the CHOC Children’s Heart Institute at 714-532-7576.

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