The goal of return-to-learn is to help cadets enrolled at the. U.S. Air Force Academy with their academic recovery post- concussion. This program was created for ...
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Return-to-Learn: A Post-Concussion Academic Recovery Program at the U.S. Air Force Academy LCDR Brian R. Johnson, MSC, USN*; Gerald T. McGinty, PT, DPT†; Lt Col Jonathan C. Jackson, MC, USAF‡; Thea M. Ramsey§; Marcus Hjalber*; C1C Taylor E. Hill, USAF*; Christopher J. D’Lauro, PhD*
The goal of return-to-learn is to help cadets enrolled at the U.S. Air Force Academy with their academic recovery postconcussion. This program was created for several reasons. First, cadets are at a higher risk for concussion injury compared with typical college students due to their increased level of physical activity. All cadets participate in sports as a National Collegiate Athletic Association (NCAA) athlete or as a competitor in club or intramural sports. Graduation requirements stipulate that all cadets complete 10 physical education classes and several strenuous military training events. To put this in context, during the 2016–2017 academic year, there were 277 diagnosed concussions at the Air Force Academy. This continues to be a prevalent diagnosis within the Department of Defense as there were 15,460 mild traumatic brain injuries in 2016.1 Second, cadets have demanding schedules. In addition to athletics, they take full academic course loads and have military responsibilities. Attendance at all of these activities is mandatory. Thus, there is little time available to rest post-injury. Third, academic faculty need a mechanism by which they can make academic accommodations for cadets. Prior to returnto-learn, an injured cadet’s engagement with academics was either all-or-none, i.e., an injured cadet was placed on bed rest and they did not participate in academics or they were medically cleared and expected to engage fully in academics. As described below, return-to-learn provides a graduated return to
*Department of Behavioral Sciences and Leadership, U.S. Air Force Academy, 2354 Fairchild Drive, Suite 6J-101, USAF Academy, CO 80840 †Sports Medicine, Athletic Department, U.S. Air Force Academy, 2169 Field House Drive, U.S. Air Force Academy, CO 80840 ‡10th Medical Group, 4102 Pinion Drive, U.S. Air Force Academy, CO 80840 §School of Mind, Brain and Behavior, University of Arizona, Tucson, AZ 85721 doi: 10.1093/milmed/usx106 Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.
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academics so cadets only participate in activities that do not exacerbate their concussion symptoms. Fourth, the most recent Consensus Statement on Concussion in Sport2 states that schools “should offer appropriate academic accommodation and support to students recovering from sports-related concussion.” Thus, we created a return-tolearn program to be consistent with the current standard of concussion care. Our program was created by reviewing available NCAA return-to-learn programs3 and then selecting and modifying the best practices for our institution. A cross-mission element team that included members from the Dean of Faculty, Athletic Department, and the 10th Medical Group collaboratively contributed to this program. Our program is consistent with the Interassociation Consensus: Diagnosis and Management of Sport-Related Concussion Best Practices. Further, the NCAA Concussion Safety Protocol Committee approved our program. We have taken best practices from many return-to-learn programs to better integrate concussion care and academics at the Air Force Academy. Going forward, we will measure whether this program will increase the likelihood of concussion self-report, improve academic performance, and ultimately benefit retention at the Air Force Academy. The following is the U.S. Air Force Academy return-tolearn program in its entirety. The remainder of this commentary is a handout that was prepared for faculty and military leadership to help them manage an injured cadet’s academic recovery.
U.S. AIR FORCE ACADEMY RETURN-TO-LEARN PROGRAM Return-to-learn is a parallel concept to return-to-play. Whereas, return-to-play focuses on the return to physical activity post-concussion, return-to-learn focuses on the return to cognitive activity and full academic participation. Return-to-learn guidelines assume that both physical and cognitive activities require the utilization of brain 1
Commentary
energy. After a cadet incurs a concussion, the cadet experiences a brain energy crisis in which brain energy is not available for physical or cognitive exertion4. Thus, this protocol exists to allow the cadet to heal during this energy crisis and prevent premature return to academic activities. It is important to watch for the following characteristics in a concussed cadet: • • • • • • •
Increased problems with attention and/or concentration Difficulty with remembering or learning new information Longer time needed to complete tasks Inappropriate or impulsive behavior Greater irritability and/or emotionality Decreased ability to cope with stress Difficulty or distress in a stimulating environment Physical symptoms such as:
• • • •
Headache Nausea Dizziness Fatigue
These are all symptoms of a concussion and an increased intensity or onset of new symptoms may demonstrate a need for slower return-to-learn and additional medical attention. The presence of these symptoms for longer than 3 wk signals a need for further medical attention. If you witness a cadet demonstrating these symptoms, please escort them to the Cadet Clinic.
PROTOCOL MANAGEMENT After the diagnosis of a concussion, the cadet’s academic advisor and air officer commanding (AOC) will manage his/ her return-to-learn. These personnel will work with the cadet and his/her instructors, professors, as well as medical staff in order to develop a customized plan. As the cadet moves through the return-to-learn stages, the academic advisor and AOC will provide updates on his/her progress. Personnel in the Cadet Clinic will assign the return-to-learn stages and will maintain and disseminate accurate concussion recovery updates. It is imperative that AOCs and academic advisors provide feedback to medical personnel on their concussed cadet’s academic progress. Returning to the classroom does not mean the cadet is symptom-free. The gradual return to full academics (i.e., caught up with syllabi in all classes) should be modified individually for each cadet based on symptoms and course content. Return-to-learn is completed in several stages and symptoms are monitored at each stage. Certain activities may trigger new symptoms or worsen existing ones. In this case, the cadet may need to be reevaluated by medical personnel. Cadets with a concussion are seen at least once per week in the Concussion Clinic. 2
Concussion and mild traumatic brain injury are covered under the Americans with Disabilities Act Amendments Act (ADAAA). Any action taken in this process must remain compliant with the ADAAA law. RETURN-TO-LEARN STAGES The program consists of five stages that move the individual from full rest to full class attendance. Each stage contains academic activities that will help to determine how well he or she is progressing. Once the threshold for that stage has been met the cadet should progress to the next stage. The duration of each stage should be specific to each individual cadet and is based on the symptoms experienced by the cadet. Stage 1 – Cognitive Rest (Typically Same Day of Injury) Following the diagnosis of a concussion, the cadet should immediately begin cognitive rest. This means avoiding activities that require cognitive energy, including (but not limited to) classroom attendance, formation, briefings, homework, “screen time” (i.e., phone, computer, video game use), reading, driving, bright lights, and loud noises (e.g., meals should be provided in the cadet’s dorm in order to avoid Mitchell Hall). The day of the concussion, the cadet should remain in their dorm in order to avoid cognitive stressors such as loud noise and bright lights. Due to the energy crisis that occurs after a concussion, cognitive rest allows the brain to heal more quickly. While the cadet is still experiencing symptoms without stressors or activity, they should remain at the cognitive rest stage. When the cadet is asymptomatic at rest, they will progress to the next stage. Stage 2 – Trial of Cognitive Activity (Return to Homework) Cadets can begin to participate in cognitive activity such as homework or reading for 30 min followed by a 15 min of rest. If symptoms do not develop, cognitive activity can be increased to 45 min followed by 15 min of rest. If the cadet develops symptoms after participating in activities, they should rest until symptoms subside. Also, the cadet can begin to attend morning accountability formation and briefings. Once the cadet can complete approximately an hour of cognitive activity without the onset of concussion symptoms, they will progress to the next stage. Stage 3 – Return to Class (With Maximum Modifications) The cadet can return to a partial day of classes, avoiding specific classes or activities that lead to the onset of symptoms, such as particularly challenging classes, labs, and excessive computer use. The cadet should not participate in physical education classes. Cadets should communicate to professors and instructors when they are experiencing symptoms and ask to leave class or modify classes (see Table I) in order to MILITARY MEDICINE, Vol. 00, 0/0 2018
Commentary TABLE I.
A Selection of General and Symptom-Based Accommodations for Professors/Instructors to Consider
Symptom General
Headaches
Sensitivity to noise
Sensitivity to light
Sleep difficulties Visual problems
Concentration/ memory problems
Dizziness/ lightheadedness
Accommodation • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Modify or cancel an assignment(s) Short in-class breaks Extended time on assignments or quizzes/GRs Quieter/dimmer exam room Ability to record lectures or provide note takers Alternative forms of quizzes and GR’s e.g., oral instead of written, paper instead of computer Excused absences Schedule change Drop a class that induces concussion symptoms Allow cadet to lay head down on desk Allow frequent breaks Identify triggers that cause headaches to worsen No physical education classes, band, or chorus Avoid loud classes/labs Permit earplug use Avoid Mitchell Hall; eat in a quiet setting Avoid attending athletic events, gymnasiums (e.g., Falcon Stadium) Allow cadet to leave/arrive from class early/late to avoid loud hallways Limit cell phone, head phone/ear phone use Allow cadet to wear sunglasses Move cadet to area with low-lighting, dim lights Avoid sitting in direct sunlight Avoid bright projector/computer screen Allow late start to school (e.g., cadet may need to miss morning accountability formation) Allow frequent rest breaks Limit computer use Reduce/shorten reading assignments Record lectures or use auditory learning apps Allow for more listening and discussion vs. reading Increase font size on computer/projection screen Limit texting/video games Limit watching TV close up or from a distanceSeat cadet closer to the center of the room (for blurry vision) Place main focus on essential academic content/concepts Postpone major GRs or participation in standardized testing Allow extra time for assignments, quizzes, GRs, projects Modify class assignments and homework Limit to one exam per day Consider use of pre-printed notes, note taker, or reader for oral test taking Allow cadet to leave class early to avoid crowded hallways Provide an escort Allow cadet to put head on desk
minimize the experience of concussion symptoms. The cadet should not take quizzes or exams, as a taken one while concussed will be unlikely to accurately represent the ability and knowledge of the cadet. Cadet can begin to make up work missed when they were not in class. Once the cadet can complete a partial day of classes without the onset of concussion symptoms, they will progress to the next stage. Stage 4 – Return to Class (With Minimum Modifications) The cadet can return to a full day of classes but should take breaks when necessary. The cadet can begin to take quizzes and GRs, although they should be adapted in order to prevent triggering symptoms (i.e., oral exam instead of written, MILITARY MEDICINE, Vol. 00, 0/0 2018
paper instead of computer, etc.). Single class exceptions for a particular class that provokes symptoms may be necessary. Once a cadet can attend classes without the onset of concussion symptoms, they will progress to the next stage. Stage 5 – Full Class Attendance (No Modifications) The cadet returns to classes as usual, fully participating and taking all quizzes and GRs in the original format. The cadet will continue to work with professors and instructors in order to ensure that any missed work is made up and they are caught up to the syllabus. Continue to monitor for concussion symptoms, even after the cadet has reached stage 5. Any return of symptoms should be referred to a medical professional. 3
Commentary
Symptoms Persisting Longer Than 3 wk For most cadets, concussion symptoms will subside and a full return to class with no modifications will occur within 3 wk. For those cadets who continue to experience symptoms past the 3-wk period, there are differing ways to make academic adjustments and accommodations. The cadet may need a change in schedule (e.g., drop a class); special arrangements may be required to allow for extended absences, quizzes and GRs, term papers, and projects.
CONCLUSION We are currently institutionalizing this program at the Air Force Academy. Further, we will monitor enrollment into this program and track any effects on retention rates due to medical turn back.
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ACKNOWLEDGMENTS We thank the National Collegiate Athletic Association and the Department of Defense who supported the development of this program through a Mind Matters Research Challenge grant.
REFERENCES 1. Defense and Veterans Brain Injury Center. DoD Worldwide Numbers for TBI. Available at https://dvbic.dcoe.mil/dod-worldwide-numbers-tbi. accessed October 9, 2017. 2. McCroy P, Meeuwisse W, Dvořák J, et al: Consensus statement on concussion in sport – the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017; 51(11): 838–47. 3. National Collegiate Athletic Association Sports Science Institute Concussion Safety Protocol Management. Available at http://www.ncaa.org/sportscience-institute/concussion-safety-protocol-management. accessed June 14, 2017. 4. Giza C, Hovda D: The neurometabolic cascade of concussion. J Athl Train 2001; 36(3): 228–35.
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