Beyond Safety Protocols: Concussion Management for Learners

On a Saturday morning in September 2004, Jake Snakenberg, a 15-year-old fullback at Grandview High School in Aurora, Colo., collapsed during a freshman football game. He did not regain consciousness and died the next day.

Witnesses reported Snakenberg had not taken any hard hits during the game. In the days following his death, Karen McAvoy, the school psychologist at the time, recalls everyone asking the same question: Did anyone know that Jake was at risk?

“It was the early days, and we had little awareness about concussions,” says McAvoy, who today directs the Center for Concussion at the Rocky Mountain Hospital in Denver, Colo. Now, she and other experts realize that even mild brain trauma with few visible symptoms can have serious health consequences.

Follow-up reports suggested Snakenberg had suffered a concussion in his previous football game, but the warning signs of brain injury had been minimal. He had complained only of transient tingling in his hands. He told family and friends he was ready to play.

Snakenberg’s death changed McAvoy’s life. On the professional level, it launched her career as an advocate for K-12 concussion education in the Cherry Creek Public Schools before she moved to her current position.

McAvoy and colleagues responded to Snakenberg’s death by developing a districtwide concussion management system to prevent another tragedy. The school system made the care of high school and middle school athletes’ injuries the top priority of concussion management. The group devised a framework to guide their work as well as a process to share information.

School administrators will find better resources are available. Notably, these include the guidelines McAvoy developed, known as REAP (Remove/Reduce, Educate, Adjust/Accommodate and Pace). They are used in eight states.

Incremental Gains

“An effective concussion management program can start small,” says McAvoy. “Most do.”

At Cherry Creek, a school system with 54,700 students spread across 61 campuses, the robust concussion management system that exists today is the result of many years of refinement that grew under McAvoy and continues to be refined.

Six characteristics of its plan for managing student concussions stand out: (1) ongoing superintendent support rather than a lone champion or sporadic attention; (2) K-12 coverage, not just high schools; (3) a graduated, accommodated return to academics; (4) monitoring for an extended time; (5) established protocols rather than in-the-moment decisions; and (6) an extensive communication network with families, staff and community members, not just nurses, athletic coaches and trainers.

Districts with large enrollments and a wider array of community resources have made steps forward; smaller districts and schools are embracing the ideas of REAP or other programs, such as BrainSTEPS, to strengthen solutions. No national statistics are collected on concussion management systems, so we don’t know whether the percentage is large or small.

“Every district has strengths and limitations. In a small community, there may only be one person on a school team who manages the symptoms. That one person can still partner with a family member and someone from the medical team,” McAvoy writes in her REAP guidelines, which suggest “more varied perspectives (even if only three perspectives!) lead to better decision making.”

The good news, says McAvoy, is that a return-to-learn policy does not have the additional staffing costs of return-to-play, which may require hiring athletic trainers and other personnel. At least initially, return-to-learn practices simply mean educating school staff who come in contact with affected students, she says.

Evolving Protocols

A strong concussion management program addresses four essential elements: medical, physical (school athletics), academics and the family. These are connected but not always overlapping domains.

The greater emphasis on a cautionary return-to-learn means students should be monitored post-injury for potentially up to four to six weeks. All concussed students need a lighter cognitive load during this time frame, which requires substantial communication and coordination between administrators, teachers, student and family.

Managing symptoms is challenging given that concussions present differently in individuals and may vary over the course of a day or week, says McAvoy. Students may perform well in class and then falter, requiring their academic load be adjusted.

Protocols must be well-considered, established, timely and consistent to ensure optimal outcomes for students. They should reflect best practices, including a gradual return to a full academic load and a mandate that students regain their academic capacity before a gradual return to athletics.

Onboarding Staff

The first step for a concussion management system is creating a communications framework that includes administrators, health staff, teachers, coaches, families and medical practitioners.

In McAvoy’s experience, creating an effective communications network is the most challenging measure because it involves multiple parties with varied interests and responsibilities who don’t regularly work together. Their focus must be to prevent concussions and improve care and management after a concussion — across buildings, age groups and genders.

School staff require information and training on the full array of concussion symptoms, which include headaches, nausea, blurred vision, sensitivity to noise, difficulty concentrating or remembering, anger, depression, drowsiness and mental fatigue. Staff members also need to know about interventions and false assumptions. Teachers might blame a student for being lazy and unmotivated when the reason might be cognitive fatigue or difficulty processing new information, which are common side effects of a concussion.

School-Level Teams

School nurse Jaimie Sweem vividly recalls the distress of a student who visited her office in fall 2011. At the time, Sweem worked at Indian Land High School, part of the 12,000-student Lancaster County School District in South Carolina. The student told her he thought he had suffered a concussion — a full month earlier. He hadn’t told anyone at the time and admitted to struggling to finish class assignments and tests. His academic performance had plummeted.

Sweem was flummoxed. She found neither the school district nor the state had established guidelines for follow-through. Sweem and her husband David, an assistant principal and assistant football coach at the high school, immersed themselves in concussion research and best practices. They attended a conference where McAvoy was a presenter. “We got a ton of information,” says David Sweem, who also has worked as a certified athletic trainer.

The Sweems built their own concussion management system, which they piloted at the high school. It subsequently was adopted by the district for use at all schools.

“We want to do what’s right for kids, not just what’s legally required,” he said.

The situation in Lancaster County is not without shortcomings. The district lacks someone to consistently oversee the concussion management program. It’s a matter of limited resources and competing priorities, all pressing. Indian Land found at least part of the answer within the system — the Sweems created a school-level team at the high school.

Districtwide Practices

In Nebraska’s Lincoln Public Schools, the state’s second largest district with nearly 41,000 students and 60 campuses, special education supervisor Cindy Brunken oversaw concussion management for years before her retirement in June.

“Getting people to understand the importance and relevance was not always easy,” Brunken admits. “There has been a lot of awareness training.”

Brunken credits her boss, Superintendent Steve Joel, for progress on this front. “He’s been tremendously supportive of this initiative, and it needs administrative support because it directs how we spend our time,” she says. “That opened the door for me to speak to administrators and train building staff members.”

Central-office backing enabled Brunken to get concussion management on the agenda of every school in Lincoln, all of which now have concussion teams consisting at least of an administrator, speech pathologist and nurse. High school concussion teams typically include an athletic trainer, school psychologist and a teacher.

As chair of the Southeast Nebraska Brain Injury Regional School Support Team, Brunken helped develop return-to-learn guidelines for the state, a helpful resource for school districts.

Smaller Networks

Smaller districts have fewer resources, but also smaller networks to manage and often a more homogenous student body.

Eric Eshbach, superintendent of the 3,200-student Northern York County School District in Dillsburg, Pa., says educators used to think concussions “were no big deal. Kids were just told to try a bit harder and get on with things.”

His district is in the third year of a return-to-learn concussion management model created by BrainSTEPS, which the Centers for Disease Control and Prevention recently recognized as a national model.

BrainSTEPS, developed by the Pennsylvania Department of Health, calls for establishing a district team and support network to re-spond to suspected or diagnosed cases. It involves training school personnel to identify symptoms and links them to consulting experts and resources on treatment and appropriate delivery of education services to affected students, from school re-entry to graduation, even when students appear to have recovered. That’s because cognitive issues may manifest as the brain matures and academic demands and social activities become more complex.

Eshbach lauds a school nurse and a guidance counselor for launching his district’s concussion management program. The primary benefit has been a consistent and timely response to students who sustain a concussion.

Local Champions

School districts’ work on concussion recovery typically has been spurred by litigation or state legislation, but true progress requires local champions who persistently further the cause. “And finding a champion at every school is hard,” says McAvoy.

Not surprisingly, financial and staff resources are major hurdles. Small and rural districts may lack the obvious champions of a larger school, such as a full-time nurse or athletic trainer, let alone a school psychologist. “They may ask about what to do if no doctors are nearby, whether like districts have protocols to share,” McAvoy says.

In programs such as REAP and BrainSTEPS, information about proven practices is available and sharable. The issue isn’t a lack of knowledge, she says, but how best to disseminate it broadly and accurately. “It’s a lot like having one language with a lot of dialects representing different groups — teachers, doctors, trainers, parents, students. It comes down to old-fashioned communication and collaboration.”