Return to learning after a concussion and compliance with recommendations for cognitive rest  
Olympia RP., Ritter JT., Brady J., Bramley H. Clin J Sport Med. 2015. Ahead of Print
Take-Home Message: There is a wide variability in compliance of schools and school nurses with national recommendations for return to learning following a concussion.
Following a concussion cognitive functions such as attention, memory, and concentration are affected, which leads to potential difficulties at school. Many national recommendations stress the need for cognitive rest to facilitate recovery. These position statements suggest who should be involved (nurses, physician, athletic trainer) and how to return an athlete to school without overstressing cognitive function to the point of worsening signs and symptoms. However, there is little to no research dedicated to a student’s return to learning following a concussion. Therefore, the authors evaluated the compliance of schools in the United States with nationally published recommendations (Halsteadet al., 2010; Halsteadet al., 2013; McGrath et al., 2010) for cognitive rest in students who sustain a concussion, and determined the compliance of school nurses with recommendations as delineated by the National Association of School Nurses (NASN) position statement on their role in the management of the post concussion student. The authors developed an affirmative response questionnaire, based on the 17 recommendations for cognitive rest and electronically distributed the questionnaire 3 times during the 2012 to 2013 academic year. Out of the 2,872 questionnaires sent out to members of the NASN, 1,033 were completed and returned for analysis (36% response rate). Many of the school nurses were registered nurses (91%), have been working for over 5 years (82%), and had special training in the recognition and/or management of concussions (66%). Almost half of the school districts in this cohort had a policy in place to help students recovering from a concussion succeed when they return to school (46%), and 53% of the schools had guidelines in place to assist students in returning to school after a concussion. The most common guidelines provided by the school were excused from team sport practices and gym (87%), extension of assignment deadlines (87%),  excused absence from school (84%), and rest periods during the school day (84%). The least common guidelines implemented were use of a note taker (34%), use of a tutor (31%), limiting weight of backpack and stair usage (25%), use of a reader (20%), and use of dull colored paper to reduce light sensitivity (9%). Once a student was at school, a nurse was typically the person most responsible for overseeing a student’s concussion treatment plan (63%), followed by the student’s guidance counselor (10%). Fifty percent of the nurses reported that they communicate regularly with the athletic trainer regarding progress or setbacks encountered during the return to learn process.
School nurses have the knowledge, experience, and specialized training necessary to assist athletic trainers with the student’s return to learning following a concussion injury. However, only half of the schools have implemented return to learning guidelines following a concussion. What is more alarming is that the guidelines employed by the schools do not seem to be detailed enough to comply with the recommendations within the position statements. Out of the 17-guideline recommendations, 9 guidelines were implemented in less than half of the school’s protocol. It was also noted that only 50% of the nurses communicate regularly with an athletic trainer. A multidisciplinary team approach involving communication needs to take place to augment recovery. More research is necessary on how to train and motivate nurses, athletic trainers, parents, and physicians to create a multidisciplinary team approach to return to learning following a concussion. Medical professionals should be aware of the return to learning recommendations and have an open dialog to ensure a student’s successful return to learning following a concussion.
Questions for Discussion:
Does your school have a return to learning protocol? Do you communicate with
your school nurse about concussed student-athletes? Who is in charge of the
student’s return to learning?
Written by: Jane McDevitt, PhD
Reviewed by: Jeff Driban
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Olympia RP, Ritter JT, Brady J, & Bramley H (2015). Return to Learning After a Concussion and Compliance With Recommendations for Cognitive Rest. Clinical Journal of Sport Medicine PMID: 25961156