Post-Concussion Dizziness: An Integrated Approach to Treatment and Recovery
Concussion injuries can trigger a multitude of symptoms, each unique and complex in its own right. The severity of these symptoms can vary considerably, ranging from barely noticeable to exceptionally…
A concussion, no matter how minor it may seem, can significantly impact a student’s academic performance. The symptoms alone, such as headaches, dizziness, light sensitivity, and noise intolerance, can make it difficult for students to focus in class. Even completing homework can be a challenge due to mental strain, eye tracking & visual problems. Additionally, certain triggers, such as reading or staring at a screen, can exacerbate these symptoms. Tests and quizzes can also be a challenge for students as they may have difficulty with other symptoms such as recalling information due to the traumatic brain injury.
To ensure the best possible outcome, a healthcare provider needs to create an appropriate academic re-entry plan as part of their patient’s graduated return to learning (GRTL) process. A comprehensive GRTL plan should take into account any lingering symptoms of concussion that may affect a student’s abilities. In this blog post, we will discuss what components are necessary for creating an effective academic re-entry plan, and provide helpful tips on how to ensure your patient is provided with the necessary support.
Identify and Prepare for a Graduated Return to Learn Plan
A student’s specific post-concussion symptoms are the cornerstone of creating an effective academic re-entry plan. The ability to track symptoms over time will inform how and when to progress the student. Validated, age-appropriate symptom scales are available in print (such as the SCAT6/SCOAT, Child SCAT6), as well as electronically (like the Concussion Tracker app). Whichever tool is chosen, it should be used consistently throughout the plan of care.
Research shows that 93% of student-athletes of all ages with head injuries had a full return-to-learn with no additional academic support by 10 days. (6) Once symptoms have eased, students may return to school, even if minimal learning is possible. A 2023 study in JAMA demonstrated that a return to school can precede a return to learning. It found that prolonged absence from school after a concussion is associated with a greater symptom burden and may be detrimental to recovery. (1)
Online classes are more common since the pandemic, which can be a problem for students with visual symptoms, or who are particularly sensitive to screens. For those students, extra consideration is needed for return to school, as well as academic progression based on symptom triggers.
Available Resources to Return a Concussed Person to School
There are several tools available to assist the healthcare provider once the physical exam is complete, symptoms are identified, and the patient is ready to begin the return to school process.
American Academy of Pediatrics
American Academy of Pediatrics
Consensus for Essential Elements in Returning to Learn Following a Concussion
McAvoy et al included a wide variety of professional disciplines who participate in the care of restoring brain function following a concussion. The resulting consensus elements were as follows: (2)
Numerous positive social and emotional benefits are gained by being at school, even during recovery from a head injury. Unless contraindicated by a serious medical complication, a student with a mild traumatic brain injury should return to school/learn even before symptoms are 100% resolved, provided the student can manage fluctuating symptoms, and the school concussion management team has received training and resources to support the student in the educational setting.
A concussion management team should include representatives from school academic, school physical/health services, medical, and family/student domains who work collaboratively to develop and adjust an individualized Return to Learn plan.
Academic adjustments written into the Return to Learn plan are best overseen and directed by school professionals with dedicated expertise and knowledge of educational law, policy, and curriculum.
Determination of progress should include monitoring of concussion symptoms, as well as academic monitoring, no less than one time per week.
Schools have existing educational safeguards to support all students who struggle academically, medically, psychologically, and socially at school. Concussions can be included and managed using the existing educational safeguards.
Schools should provide increasing tiers of academic support for students with concussions that do not resolve in a typical timeframe. They need not delay or postpone academic support while awaiting community health care input if medical insight is not timely or available.
Data from a neuropsychological evaluation is not required, but can be helpful and should be considered and may be incorporated into a Return to Learn plan if available.
6th International Consensus Statement on Concussion in Sport (June 2023)
The long-awaited update to the Berlin consensus statement outlines a graduated return-to-learn strategy that includes four distinct steps:(7)
Daily activities that do not result in more than a mild (+2 out of 10) exacerbation of symptoms. 5-15 minutes of typical activities while minimizing screen time is allowed with gradual increases.
School activities such as homework, reading, or other cognitive work outside of the classroom are added to increase tolerance and ability to manage the mental effort.
Return to school part-time, gradual introduction of schoolwork, and potentially greater access to breaks throughout the day.
Return to school full-time, progressing in school activities until a full day can be tolerated with minimal symptom exacerbation. Catching up on missed work is also included.
If symptoms are elevated more than +2 out of 10, or if the symptoms linger for more than a brief period, the progress of the student is slowed until tolerable. The Consensus Statement also stresses the importance of minimizing academic and social disruptions, and that healthcare providers should avoid recommending full rest and isolation. Even in the first 24-48 hours post-injury, “relative rest” rather than complete rest is preferred, allowing for mild and brief symptom increase.
Another valuable tool for the healthcare provider isREAP®, which stands for Remove/Reduce • Educate • Adjust/Accommodate • Pace. It is a comprehensive guide for return-to-learn that incorporates interdisciplinary roles for medical, academic, parent, and athletic stakeholders. The Certified Athletic Trainer, School Nurse, Counselors, Teachers and Administrators, Students, Parents, and Healthcare Professionals all have specific strategies and goals for students returning from head injury. (8)
Individualized Plans Based on Concussion Symptoms
The return-to-learn process should be customized for each student based on their unique needs and symptoms. Ideally, modifications are specific to their unique symptom triggers. Here are some examples of modifications, based on a student’s common symptoms:
Cognitive Fatigue/ Decreased Brain Function:
Alternate days for morning classes and afternoon classes
Take frequent breaks
Limit in-class activities
Difficulty Concentrating/ Mental Processing:
Only one test per day
Quiet study/learning environment
Allowing a billed cap to be worn in class
Sitting further away from windows
Dimming overhead lights
Pre-printed notes for class material
Limited computer bright screen use, or reduce monitor brightness
Change classroom seating to the front of the room as necessary
Memory Loss/ Difficulty Remembering:
Prorate workload (only core or important tasks)
Eliminate non-essential work
Reduce the amount of nightly homework
Extra tutoring/assistance requested
The plan should gradually increase the level of academic activity as tolerated by the student. School staff is responsible for ensuring these modifications are applied, but it is the healthcare provider’s responsibility to provide a medical letter to facilitate the provision and receipt of academic accommodations. Regular adjustments are necessary so that the student is neither rushed, nor unnecessarily delayed in progressing their schoolwork, and also to identify a lack of progress and need for further testing. (3)
Additional Recommendations for Managing Students with Brain Injuries
Other steps the healthcare provider should consider when forming an academic re-entry plan include:
regular follow-up assessments
providing accommodations such as extra time on exams or assignments
encouraging self-advocacy skills so they can effectively communicate their needs to teachers and classmates
creating a supportive environment at home establishing healthy sleep habits to promote physical and mental well-being
Barriers to Successful Academic Re-entry
Potential challenges may arise in implementing a graduated return to learn plan after a traumatic brain injury. If symptoms worsen often, the student risks a delay or setback in recovery.
Mental Health Symptoms of Concussion
Patients not only experience physical discomfort from headaches, dizziness, etc, but the impact on mental health can further heighten their dysfunction. Anxiety and stress are well known to increase symptoms (11, 12, 13), and can further impede their ability to learn.
The lack of contact with friends, teammates, classmates, and peer groups in general, can create a sense of missing out, isolation, and distress. Some concussion patients are accused of malingering and are vulnerable to bullying.
Falling behind in grades is also a real concern, especially if the student struggles to understand the material due to post-concussion symptoms. Stress, anxiety, and depression symptoms get worse with these academic pressures, especially for students in accelerated classes, intense college majors, facing deadlines, or with pre-existing learning difficulties.
Brain Injury and Learning Differences
For students with dyslexia, ADD/ADHD, certain types of neurodiversity, or learning disabilities, the challenges can be further compounded. Frustration can lead to irritability, which can cause concentration, memory & focusing to worsen. For these students in particular, teachers and staff need to provide additional individualized attention and accommodations if needed. This could include more frequent breaks throughout the day, modified assignments, increased tutoring, or assistive technology.
Institutional challenges can also interfere with a concussed person having a successful academic re-entry after a concussion. Researchers investigated the development of communication patterns and the use of a return-to-learn protocol to facilitate GRTL. The review included twenty-eight publications and revealed three themes: lack of policy, poor staff education on concussion symptoms, and stakeholder communication breakdown. (4)
Social Determinants of Health and Brain Injuries
Consideration of social determinants of health (SDOH) is an essential factor in preparing a student to return to school. SDOH includes factors such as income and education level, race/ethnicity, gender identity, sexual orientation, living environment, access to healthcare, and other social circumstances. Any circumstance that can negatively influence a student’s success after a brain injury must be addressed.
SDOHs that create trouble for concussion patients include:
lack of access to tutoring
lack of support and/or bullying regarding necessary modifications
lack of a conducive home learning environment
lack of consistency with a primary healthcare provider
financial concerns may limit access to further testing or services
SDOH and Concussion Tests
In addition, studies have found that common concussion testing results vary across socioeconomic and racial populations. Wallace et al looked at vestibular/ocular motor screening (VOMS) and King-Devick (K-D) test performance in high school student-athletes. Racial and socioeconomic status (SES) differences existed in test results at baseline. The study concluded, in part: “With a higher probability of undiagnosed and uncorrected vision impairment, vestibular dysfunction, and saccadic eye tracking deficits likely to be more apparent as a consequence of poverty or health inequities, it is important that healthcare providers, especially those that diagnose and treat concussions, understand that performance on the VOMS and K-D tests at baseline may be subject to sociodemographic factors of SES and race.” (9)
Head Injury Requires Emotional & Psychological Support
Parents and teachers must be understanding and supportive of students who are recovering from a head injury. The healthcare provider can inquire during regular check-ins whether parents and teachers are taking the time to talk openly about how the student is feeling, providing them with the identified modifications at home and school, and helping them create achievable goals and practical strategies.
The emotional impact of a traumatic brain injury can lead to significant challenges in promoting successful academic reintegration. Studies show that social support and patient empowerment significantly improve recovery outcomes. (10) Providing guidance, resources, and encouragement can help students with brain injuries feel supported and motivated at school. Unnecessary pressure, lack of emotional support/empathy, or unrealistic expectations can lead to setbacks that compromise best outcomes.
Other Brain Injury Considerations
Access to on-campus services
Bear in mind that specific needs exist for different grade levels. For instance, elementary school students require recess & playground activities to be addressed. Older students have multiple teachers throughout their day and have larger projects, midterms, final exams, etc. Elementary school through high school students may have trouble with access to a guidance counselor, school psychologist, or school nurse.
College students should seek out a student resource center on campus to provide the necessary framework for making any changes to their academic plan. Given that there are rarely outward physical signs of concussion, a lack of familiarity with assisting such students can complicate access. A person with headache, nausea, balance problems, brain fog, dizziness, memory or concentration issues must be taken at their word that accommodations are necessary. The healthcare provider can facilitate the process with well-documented medical necessity.
Critically, high schools, colleges, and universities have a distinct advantage by having athletic trainers who are instrumental in bridging the medical and academic needs of the student.
Head Injury Symptoms in the Non-Athlete
Not all students with concussions participate in sports. Head injuries from a car accident, fall, physical abuse, or any type of head trauma can occur in elementary through college-age students. The brain doesn’t necessarily care ‘how’ it was injured, and the mechanism may have caused additional injuries.
Occasionally, a hospital stay, physical therapy for neck pain, or prioritizing other injuries may delay a return to school. Given the complexity of head injury cases, the whole person should be considered during the initial healing period.
For students who are not athletes or whose injury was not related to sports, recess, physical education classes, and after-school activities should be addressed. In addition, students exposed to extracurriculars that may provoke symptoms may need modifications. For instance, band/choir practice (noise/sound), dramatic arts (mental focus, stage light sensitivity, memorization), gaming (screens, visual symptoms), and dance (balance, choreography, peripheral vision) all have the potential to influence recovery from a brain injury while at school but are not necessarily academic.
Post-concussion Syndrome or Persistent Concussion Symptoms
PCS is of particular concern for students with head injuries. The person may experience physical, cognitive, and emotional symptoms months after the initial injury has resolved. Special considerations are necessary to address these ongoing issues that can negatively influence academic performance. In particular, trouble with concentration, focusing, sleep problems, ongoing headache pain, visual problems, trouble with memory, difficulties processing new information, and dizziness are all common PCS symptoms that can have a direct impact on a student’s ability to function and recover.
These factors can also compound and contribute to difficulties in managing emotions like irritability, depression, and anxiety. This in turn can cause sleep issues, and subsequent chronic fatigue to get worse. Clinicians who can recognize and intervene early provide their patients with a better chance to recover sooner.
Prioritizing Cognitive Symptoms Over Sports/Physical Activity
A graduated return-to-learn must be completed before a return-to-play. (4, 6, 7, 8) While there may be some overlap in the initial stages of relative rest and light, symptom-limited physical activity, a student must be cognitively healed without the need for accommodations before more intense physical exertion. The introduction of contact sports activities is secondary to academic confidence.
Brain injuries have far-reaching effects that require customized and individualized approaches to healing, which can take months. With proper support, communication, and guidance from clinicians, teachers, parents/guardians, and other school personnel, the student can successfully reintegrate back into school. The key is to understand the unique needs of each student with a head injury so that appropriate accommodations can be made. An interdisciplinary team can lead to successful reintegration back into the learning environment, considering the student’s physical, emotional, and cognitive health. Collaboration and communication between all parties are crucial to ensure the student’s success.
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Stacey Ritter, MS, ATC has over 30 years of experience in the athletic training/sports medicine profession. She has worked with all ages and competitive levels, including Olympic and professional athletes. She is the owner of Concussion Navigation Services in San Luis Obispo, CA, providing baseline testing, injury management, professional development education and consulting, using the most current, evidence-based standards of care. CNS is one of only 8 CCMI Certified Concussion Clinics in CA.
Stacey has served on a variety of boards & committees and has co-authored several resource documents for the National Athletic Trainers Association (NATA). She is a sought-after speaker at the local, state, district and national levels. Stacey has been honored with multiple awards of achievement, including both the Far West Athletic Trainers Association & NATA Most Distinguished Athletic Trainer, and NATA Athletic Training Service recognitions.