Return to Learn for the Collegiate Student-Athlete

kouturesIn 2010, the National Collegiate Athletic Association (NCAA) mandated that all member institutions develop concussion awareness and management policies. As a Medical Team Physician for California State University Fullerton, I helped develop our campus document that serves to enhance concussion education and awareness among student-athletes, parents, coaches, medical staff, and administrators.

Much of the policy referenced national consensus statements and current medical literature on concussion diagnosis and management. We presented common signs and symptoms of concussion, gave recommendations for the immediate response to a concussion, and then painstakingly outlined a sensible step-wise return to play algorithm.

Yes, a very comprehensive document, but it didn’t take long to realize that something major was missing….

We knew that cognitive capabilities are adversely affected by concussion, but hadn’t fully comprehended the actual magnitude of the anxiety facing a concussed collegiate student-athlete in efforts to return to classroom work and battling many particular challenges:

  • Large lecture halls and rapid pace of entry-level classes with little personal connection with instructors, often on the schedule of freshman students who might be away from home for the first time and have established minimal to no peer network outside of their team. Taking notes and staying engaged in this environment is a major effort in the best of times, and can be maddening when dealing with post-concussion headaches, dizziness, noise sensitivity and visual issues.
  • For upper level students, missing important lab sections or even internships without defined make-up opportunities carries a real burden of falling behind or destroying a key quarter/semester.
  • Unlike elementary or high school level classes where homework constitutes a major part of grading, college courses often feature maybe some mid-term exams, a final exam, or perhaps a few papers as the only ways to show comprehension of knowledge. Bomb or miss one of these and your grade is sinking fast.
  • Need for significant reading and problem-solving time outside the formal classroom which is a definite challenge for the injured student who cannot handle the screen or printed materials for more than a few minutes without feeling sicker.
  • Classes that are often grouped together early in the day to accommodate afternoon sport schedules create limited or no opportunity for the concussed student-athlete to rest and allow partial/full resolution of symptoms between class duties.
  • Most significant is the overwhelming sense of isolation from teammates and the sport structure that provides a sense of identity in an otherwise large and possibly impersonal setting, that often brought them to the campus in the first place, and contributes to the anxiety and even depression that further impede concentration, memory, and the ability to return to learn.

 

As we continued to hear these poignant concerns, we strove to find ways to provide tangible solutions and on-campus, practical resources to address the needs of our student-athletes, and once again, it was our patients who did most of the teaching, and we did a lot of interested listening:

  • Office of Students with Disabilities (OSD): Every campus has this resource, and it was readily apparent that many of our student-athletes were reticent to seek help, citing concerns such as “I’m not really disabled”, “I don’t really need this”, and “I’m not sure what they can do for me”.
    • To combat these concerns, we realized that having a particular contact name was truly helpful in establishing a relationship, and also creating specific outcomes increased acceptance by student-athletes
      • OSD staff would take the primary role of educating about concussions and communicating modifications to professors, taking this pressure off of the student-athlete. All it takes is one “difficult” professor to complicate things, and often with a bit of gentle education, a more understanding situation can quickly occur.
      • OSD staff would present a host of accommodations and modifications and engage the student-athlete in a mutual discussion about which ones would be most appropriate, allowing some aspect of control in an otherwise uncontrolled set of circumstances
      • Regular follow-up appointments to monitor progress
      • Regular communication with other members of the treatment team
  • Coaches and teammates: Having an educated and understanding response that acknowledged the trials and frustrations of concussion recovery was a major desire of the injured athlete. Coaches and teammates who made frequent invitations to allow safe participation in  team events (team meals, watch practice as able, films session if tolerated, helping scout opponents, community events, etc) made positive contributions to recovery and were primary factors in reducing that sense of isolation. Teammates who shared academic courses and who could assist with note-taking, recording of lectures, and other duties were also quite instrumental in the recovery process. Mandated preseason concussion awareness efforts should underscore these key points.
  • Providing criteria for Return to Learn progression: Most college students are goal-oriented and student-athletes are no exception. Much as they profess less anxiety when they are away of the specific steps needed to return to the sport field, they often will report a similar reduction in worry if given particular benchmarks needed to advance in academic efforts. If possible, focused statements such as “can partially return to lecture once you can read for 30 minutes twice in a day without headache” or “may start taking notes but no testing for now” are better tolerated than “we’ll let you get back to class when you are ready.”
  • Academic Counselors and Student Services Support: Having mandatory study hours wasn’t enough, rather having modified sessions (allowing rest periods, not using as much screen-based media or turning down brightness/increasing fonts, more 1:1 teaching, audio learning or books on tape) that addressed the particular symptom concerns of the injured athlete. Often, individualized meetings early in day before onset of cumulative fatigue were the best medium for success.
  • Medical and Psychologic Support: Regular meetings with athletic trainers, physicians, mental health experts, neuropsychologists, physical therapists and other members of the medical team to evaluate progress, offer new recommendations, and foster a multi-disciplinary approach. Student-athletes are used to being part of a team, and tend to have less anxiety and respond better to a team-based approach to their medical care. Essential that the student-athlete feels comfortable with members of the team sharing information to collaborate on a best individual treatment plan.
  • Ability to speak with others who have suffered concussions: The opportunity to share experiences with fellow student-athletes who have suffered a similar injury can be extremely helpful for many collegiate athletes, This maybe accomplished by making contacts with other athletes on the campus, or even on-line such as through Concussion Connection.
  • Evidence-based and trustworthy on-line concussion reference sites: Even though we often tell concussed individuals not to spend much/any time on-line, guess what, they still do (or their friends and families do it for them). Often they are reading up on concussion, so being proactive and providing particularly helpful sites can cut down on the search efforts, minimize information that might complicate the recovery, and give appropriate support for the concussed individual.
  • Not being afraid to seek outside help: There are times where student-athletes and their families may benefit from the additional insight of a second or additional opinion from outside the campus environment. In cases where the on-campus resources aren’t as robust or experienced, utilizing outside experts, such as the Academic Agency,  can provide essential supplemental help for the student-athlete and the on-campus treatment team.

So yes, a truly comprehensive concussion awareness and management policy would have step-wise algorithms for Return to Learn that compliment the Return to Play decisions. Once again, working in the collegiate setting is truly an educational experience for a team physician who hopes that he is able to teach his student-athletes somewhere close to the same amount that they have taught him.

 

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